New Jersey-2016-S692-Introduced

An Act establishing the Behavioral Health Insurance Claims Advocacy Program and supplementing P.L.1997, c.192 (C.26:2S-1).

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. The Legislature finds and declares that:

a. Those who suffer from mental illness and substance abuse disorders face unique challenges in navigating the bureaucracy of insurance benefits related to behavioral health care services.

b. Filing claims and appeals can be a difficult task for any person, but people with mental illness or substance abuse disorders, and their families, have the added difficulty of coping with their behavioral health problems on top of dealing with their carrier.

c. Certain carriers delay or deny the claims of people with substance abuse disorders or mental illness for a variety of reasons, including denials of medical necessity or "fail-first" policies. These denials or delays can be especially serious for people with behavioral health problems, because a delay in care can result in an increase in the severity of the problem.

d. It is, therefore, in the public interest to establish a State program that advocates for people with behavioral health problems in helping them to navigate the health insurance bureaucracy and receive the coverage to which they are entitled.

2. a. There is created within the Department of Banking and Insurance the Behavioral Health Insurance Claims Advocacy Program. The program shall:

(1) Maintain and provide an Internet website and a toll-free telephone number for consumers to call for information and assistance. The number shall be accessible to the deaf and hard of hearing, and staff or translation services shall be available to assist non-English proficient individuals who are members of language groups that meet population thresholds established by the department;

(2) Respond to inquiries pertaining to behavioral health from covered persons, including, but not limited to, those regarding policy provisions pertaining to behavioral health care services;

(3) Advocate for covered persons seeking benefits for behavioral health care services through their carriers, including providing support for filing appeals through the carriers' internal appeal system; and

(4) Where appropriate, assist covered persons in filing appeals related to behavioral health insurance claims through the Independent Health Care Appeals Program, established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11).

b. In order to meet its objectives, the program shall have access to:

(1) the medical and other records of a covered person maintained by a carrier, upon the specific written authorization of the covered person or that covered person's legal representative;

(2) the administrative records, policies, and documents of carriers to which individuals or the general public have access; and

(3) all licensing, certification, and data reporting records maintained by the State or reported to the federal government by the State that are not proprietary information or otherwise protected by law, with copies thereof to be supplied to the program by the State upon the request of the program.

c. The program shall take such actions as are necessary to protect the identity and confidentiality of any complainant or other individual with respect to whom the program maintains files or records. Any medical or personally identifying information received or in the possession of the program shall be considered confidential and shall be used only by the department, the program and such other agencies as the commissioner designates and shall not be subject to public access, inspection or copying under P.L.1963, c.73 (C.47:1A-1 et seq.) or the common law concerning access to public records. This subsection shall not be construed to limit the ability of the program to compile and report non-identifying data.

3. The commissioner shall, in consultation with the Commissioner of Human Services, adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary for the implementation of this act.

4. This act shall take effect immediately.

STATEMENT

This bill establishes the Behavioral Health Insurance Claims Advocacy Program within the Department of Banking and Insurance. The bill creates the program to advocate for people with behavioral health problems in helping them to navigate the health insurance bureaucracy.

The bill creates the program to:

(1) Maintain and provide an Internet website and a toll-free telephone number for consumers to call for information and assistance.

(2) Respond to inquiries pertaining to behavioral health from covered persons, including, but not limited to, those regarding policy provisions pertaining to behavioral health care services;

(4) Where appropriate, assist persons in filing appeals related to behavioral health insurance claims through the Independent Health Care Appeals Program, established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11).

Under the bill, in order to meet its objectives, the program has access to:

(1) the medical and other records of a covered person maintained by a carrier, upon the specific written authorization of the covered person or that covered person's legal representative;

(2) the administrative records, policies, and documents of carriers to which individuals or the general public have access; and

Under the bill, the program must take such actions as are necessary to protect the identity and confidentiality of any complainant or other individual with respect to whom the program maintains files or records.