Bill Text: NJ A3712 | 2016-2017 | Regular Session | Introduced
Bill Title: Requires certain health benefits plans to provide treatment for substance abuse and dependency when determined medically necessary by physician or psychologist.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2016-07-29 - Reviewed by the Pension and Health Benefits Commission Recommend to not enact [A3712 Detail]
Download: New_Jersey-2016-A3712-Introduced.html
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
SYNOPSIS
Requires certain health benefits plans to provide treatment for substance abuse and dependency when determined medically necessary by physician or psychologist.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance coverage for the treatment of substance abuse, and amending 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 contract provides benefits to any subscriber or other covered person [covered thereunder] for expenses incurred in connection with the treatment of [alcoholism] substance abuse or dependency when such treatment is prescribed by a [doctor of medicine] physician licensed to practice medicine and surgery or a licensed psychologist. [Such] Except as provided in subsection c. 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] substance abuse or dependency as [are hereinafter set forth] follows:
[a.] (1) Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) Treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305]; and
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by [the] The Joint Commission [on Hospital Accreditation].
Treatment or [confinement] participation at any facility shall not preclude further or additional treatment at any other eligible facility [; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract].
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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 contract provides benefits to any subscriber or other covered person [covered thereunder] for expenses incurred in connection with the treatment of [alcoholism] substance abuse or dependency when such treatment is prescribed by a [doctor of medicine] physician licensed to practice medicine and surgery or a licensed psychologist. [Such] Except as provided in subsection c. 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] substance abuse or dependency as [are hereinafter set forth] follows:
[a.] (1) Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) Treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305]; and
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by [the] The Joint Commission [on Hospital Accreditation].
Treatment or [confinement] participation at any facility shall not preclude further or additional treatment at any other eligible facility [; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract].
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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] substance abuse or dependency when the treatment is prescribed by a [doctor of medicine] physician licensed to practice medicine and surgery or a licensed psychologist. [Benefits] Except as provided in subsection c. of this section, benefits shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include benefits for the treatment of [alcoholism] substance abuse or dependency as follows:
[a.] (1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) Treatment at a State-licensed detoxification facility [licensed pursuant to section 8 of P.L.1975, c.305 (C.26:2B-14)];
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [State approved] State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by [the] The Joint Commission[on Hospital Accreditation].
Treatment or [confinement] participation at any facility shall not preclude further or additional treatment at any other eligible facility [, if the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract].
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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] policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for expenses incurred in connection with the treatment of [alcoholism] substance abuse or dependency when such treatment is prescribed by a [doctor of medicine] physician licensed to practice medicine and surgery or a licensed psychologist. [Such] Except as provided in subsection c. of this section, benefits shall be provided to the same extent as for any other sickness under the [contract] policy.
b. Every [contract] policy shall include [such] benefits for the treatment of [alcoholism] substance abuse or dependency as [are hereinafter set forth] follows:
[a.] (1) Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) Treatment at a State-licensed detoxification facility [licensed pursuant to P.L1975, c.305]; and
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by [the] The Joint Commission [on Hospital Accreditation].
Treatment or [confinement] participation at any facility shall not preclude further or additional treatment at any other eligible facility [; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract] .
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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] policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for expenses incurred in connection with the treatment of [alcoholism] substance abuse and dependency when such treatment is prescribed by a [doctor of medicine] physician licensed to practice medicine and surgery or a licensed psychologist. [Such] Except as provided in subsection c. of this section, benefits shall be provided to the same extent as for any other sickness under the [contract] policy.
b. Every [contract] policy shall include [such] benefits for the treatment of [alcoholism] substance abuse or dependency as [are hereinafter set forth] follows:
[a.] (1) Inpatient or outpatient care in a [licensed hospital] health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
[b.] (2) Treatment at a State-licensed detoxification facility [licensed pursuant to P.L.1975, c.305] ; and
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by [the] The Joint Commission [on Hospital Accreditation].
Treatment or [confinement] participation at any facility shall not preclude further or additional treatment at any other eligible facility [; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract].
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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 the treatment of substance abuse or dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist. Except as provided in subsection c. 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 the treatment of substance abuse and dependency as follows:
(1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Treatment at a State-licensed detoxification facility; and
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or participation at any facility shall not preclude further or additional treatment at any other eligible facility.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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 the treatment of substance abuse and dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist. Except as provided in subsection c. 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 the treatment of substance abuse and dependency as follows:
(1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Treatment at a State-licensed detoxification facility; and
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or participation at any facility shall not preclude further or additional treatment at any other eligible facility.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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 the treatment of substance abuse or dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist. Except as provided in subsection c. of this section, the health care services shall be provided to the same extent as for any other sickness under the contract.
b. Every contract shall include health care services for the treatment of substance abuse and dependency as follows:
(1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Treatment at a State-licensed detoxification facility; and
(3) Participation as an
inpatient or outpatient at a licensed,
certified, or State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or participation at any facility shall not preclude further or additional treatment at any other eligible facility.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
d. 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 the treatment of substance abuse and dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist. Except as provided in subsection c. 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 the treatment of substance abuse and dependency as follows:
(1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Treatment at a State-licensed detoxification facility; and
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or participation at any facility shall not preclude further or additional treatment at any other eligible facility.
c. Notwithstanding any law
or regulation to the contrary, the benefits provided pursuant to this section
shall not be subject to utilization management review and the only prerequisite
or authorization that shall be needed for a covered person to obtain those
benefits shall be a determination of medical necessity and a prescription for
treatment by a physician licensed to practice medicine and surgery or a
licensed psychologist. The determination and prescription as specified by the
physician or psychologist shall control both the nature and duration of
treatment.
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 the treatment of substance abuse and dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist. Except as provided in subsection c. 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 the treatment of substance abuse and dependency as follows:
(1) Inpatient or outpatient care in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.);
(2) Treatment at a State-licensed detoxification facility; and
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or confinement at any facility shall not preclude further or additional treatment at any other eligible facility.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain those benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
11. 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 expenses incurred in the treatment of substance abuse and dependency when the treatment is prescribed by a physician licensed to practice medicine and surgery or a licensed psychologist.
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 other types of substance abuse, including drug abuse, and updates terminology in those statutes.
The bill also extends the required substance abuse 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 substance abuse and dependency include:
· inpatient or 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; and
· participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission.
Treatment or confinement at any facility shall not preclude further or additional treatment at any other eligible facility.
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 utilization management review and the only prerequisite or authorization that shall be needed for a covered person to obtain the benefits shall be a determination of medical necessity and a prescription for treatment by a physician licensed to practice medicine and surgery or a licensed psychologist. The determination and prescription as specified by the physician or psychologist shall control both the nature and duration of treatment.
