Bill Text: NJ A3161 | 2010-2011 | Regular Session | Introduced
Bill Title: Expands health benefits coverage for early intervention services provided through DHSS.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2011-07-08 - Reviewed by the Pension and Health Benefits Commission Recommend to not enact [A3161 Detail]
Download: New_Jersey-2010-A3161-Introduced.html
Sponsored by:
Assemblyman GORDON M. JOHNSON
District 37 (Bergen)
SYNOPSIS
Expands health benefits coverage for early intervention services provided through DHSS.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits coverage for early intervention services and amending P.L.2009, c.115.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.2009, c.115 (C.17:48-6ii) is amended to read as follows:
1. Notwithstanding any other provision of law to the contrary, every hospital service corporation contract that provides hospital and 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 pursuant to the provisions of this section.
a. The hospital service corporation shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the hospital service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the hospital service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a hospital service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the hospital service corporation to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The hospital service corporation may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the hospital service corporation and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the hospital service corporation of the continued medical necessity of the specified therapies and interventions.
h. 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.2009, c.115, s.1)
2. Section 2 of P.L.2009, c.115 (C.17:48A-7ff) is amended to read as follows:
2. Notwithstanding any other provision of law to the contrary, every medical service corporation contract that provides hospital and medical expense benefits and 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 pursuant to the provisions of this section.
a. The medical service corporation shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the medical service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the medical service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a medical service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the medical service corporation to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The medical service corporation may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the medical service corporation and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the medical service corporation of the continued medical necessity of the specified therapies and interventions.
h. 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.2009, c.115, s.2)
3. Section 3 of P.L.2009, c.115 (C.17:48E-35.33) is amended to read as follows:
3. Notwithstanding any other provision of law to the contrary, every health service corporation contract that provides hospital and 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 pursuant to the provisions of this section.
a. The health service corporation shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the health service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the health service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a health service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the health service corporation to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The health service corporation may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the health service corporation and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the health service corporation of the continued medical necessity of the specified therapies and interventions.
h. 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.2009, c.115, s.3)
4. Section 4 of P.L.2009, c.115 (C.17B:26-2.1cc) is amended to read as follows:
4. Notwithstanding any other provision of law to the contrary, every individual health insurance policy that provides hospital and 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 pursuant to the provisions of this section.
a. The insurer shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the insured's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the insured is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the insured is under 21 years of age and the insured's [primary] diagnosis is autism spectrum disorder, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.
h. 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.2009, c.115, s.4)
5. Section 5 of P.L.2009, c.115 (C.17B:27-46.1ii) is amended to read as follows:
5. Notwithstanding any other provision of law to the contrary, every group health insurance policy that provides hospital and 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 coverage pursuant to the provisions of this section.
a. The insurer shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the insured's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the insured is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the insured is under 21 years of age and the insured's [primary] diagnosis is autism spectrum disorder, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.
h. 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.2009, c.115, s.5)
6. Section 6 of P.L.2009, c.115 (C.17B:27A-7.16) is amended to read as follows:
6. Notwithstanding any other provision of law to the contrary, an individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal 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 by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.
a. The carrier shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.
h. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
(cf: P.L.2009, c.115, s.6)
7. Section 7 of P.L.2009, c.115 (C.17B:27A-19.20) is amended to read as follows:
7. Notwithstanding any other provision of law to the contrary, a small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal 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 by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.
a. The carrier shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.
h. The provisions of this section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
(cf: P.L.2009, c.115, s.7)
8. Section 8 of P.L.2009, c.115 (C.26:2J-4.34) is amended to read as follows:
8. Notwithstanding any other provision of law to the contrary, a health maintenance organization enrollee agreement that provides health care services and is 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 Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.
a. The health maintenance organization shall provide coverage for health care services for screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the enrollee's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the enrollee is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the health maintenance organization shall provide coverage for medically necessary occupational therapy, physical therapy, and speech therapy services, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the enrollee is under 21 years of age and the enrollee's [primary] diagnosis is autism spectrum disorder, the health maintenance organization shall provide coverage for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the coverage provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that an enrollee may make to a provider of behavioral interventions.
(2) The coverage provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum coverage amount for an enrollee in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum coverage amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum coverage amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, a health maintenance organization shall not be precluded from providing a coverage amount for an enrollee in any calendar year that exceeds the coverage amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the health maintenance organization to appropriately provide coverage for health care services, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The health maintenance organization may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the health maintenance organization and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting coverage for health care services otherwise available to an enrollee.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the health maintenance organization of the continued medical necessity of the specified therapies and interventions.
h. The provisions of this section shall apply to those enrollee agreements in which the health maintenance organization has reserved the right to change the premium.
(cf: P.L.2009, c.115, s.8)
9. Section 9 of P.L.2009, c.115 (C.52:14-17.29p) is amended to read as follows:
9. Notwithstanding any other provision of law to the contrary, 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 pursuant to the provisions of this section.
a. The contract shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the contract shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the contract shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be [promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register] adopted by the commission, with notice to covered persons of the adjustment provided, no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, the commission shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.
(cf: P.L.2009, c.115, s.9)
10. Section 10 of P.L.2009, c.115 (C.52:14-17.46.6b) is amended to read as follows:
10. Notwithstanding any other provision of law to the contrary, the School Employees' 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 pursuant to the provisions of this section.
a. The contract shall provide coverage for expenses incurred in screening and diagnosing an autism spectrum disorder or another developmental disability.
b. When the covered person's [primary] diagnosis is autism spectrum disorder or another developmental disability, or the covered person is eligible for services provided through the Early Intervention System under the Department of Health and Senior Services for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability, the contract shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative.
c. When the covered person is under 21 years of age and the covered person's [primary] diagnosis is autism spectrum disorder, the contract shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection.
(1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.
(2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.
(3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.
(b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be [promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register] adopted by the commission, with notice to covered persons of the adjustment provided, no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.
(c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.
(d) Notwithstanding the provisions of this paragraph to the contrary, the commission shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.
d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances.
e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.
f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an [individualized family service plan or an] individualized education program, or affect any requirement to provide those services[; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share].
g. The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.
(cf: P.L.2009, c.115, s.10)
11. This act shall take effect on the first day of the fourth month after enactment and shall apply to policies and contracts issued or renewed on or after that date.
STATEMENT
This bill amends P.L.2009, c.115 (C.17:48-6ii et al.), which requires health benefits coverage for certain services to persons with autism and other developmental disabilities, in order to: expand the health benefits coverage requirement for early intervention services provided through the Department of Health and Senior Services (DHSS); and make certain technical changes to clarify the provisions of P.L.2009, c.115, concerning the health benefits coverage currently required for the treatment of autism and other developmental disabilities.
The bill provides specifically as follows:
· A health insurer is to provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan, when the covered person is eligible for services provided through the Early Intervention System under DHSS for the treatment of a child with a developmental delay who has not been diagnosed as having an autism spectrum disorder or another developmental disability. (This requirement applies to: health, hospital and medical service corporations; commercial individual and group health 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.)
· In the case of a child who has been diagnosed as having an autism spectrum disorder or another developmental disability, the bill deletes the current statutory provision that limits the coverage requirement for a health insurer for services provided through the Early Intervention System to only the family cost share incurred by participants in an individualized family service plan, so that the coverage requirement for these services would be expanded to parallel that for a child with a developmental delay as specified above.
· The bill makes the following technical changes in the current provisions of P.L.2009, c.115, concerning health benefits coverage for the treatment of autism and other developmental disabilities:
-- changes references to "autism" to "autism spectrum disorder" (ASD) in order to reflect common usage in referring to this condition;
-- makes the current health benefits coverage requirements of P.L.2009, c.115 applicable to a covered person with a diagnosis of ASD, deleting references to "primary" diagnosis; and
-- stipulates that the State Health Benefits Commission, in the case of the State Health Benefits Program, and the School Employees' Health Benefits Commission, in the case of the School Employees' Health Benefits Program, is responsible for adjusting the statutorily stipulated cap on health care coverage for certain services for persons with ASD under that program.
· The bill takes effect on the on the first day of the fourth month after enactment and applies to policies and contracts issued or renewed on or after that date.
