ASSEMBLY, No. 3970

STATE OF NEW JERSEY

214th LEGISLATURE

 

INTRODUCED MAY 9, 2011

 


 

Sponsored by:

Assemblyman  CRAIG J. COUGHLIN

District 19 (Middlesex)

 

 

 

 

SYNOPSIS

     Requires health insurers and SHBP to provide certain mental health benefits for eating disorders under same terms and conditions as for other illnesses and diseases.

 

CURRENT VERSION OF TEXT

     As introduced.

  


An Act concerning health insurance benefits for eating disorders and amending P.L.1999, c.106 and P.L.1999, c.441.

 

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

 

     1.    Section 1 of P.L.1999, c.106 (C.17:48-6v) is amended to read as follows:

     1.    a.  Every individual and group hospital service corporation contract that provides hospital or 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 for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the hospital service corporation cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which a hospital service corporation determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the hospital service corporation; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the contract.

     c.     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.1999, c.106, s.1)


     2.    Section 2 of P.L.1999, c.106 (C.17:48A-7u) is amended to read as follows:

     2.    a.  Every individual and group medical service corporation contract that provides hospital or medical expense benefits that 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 for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the medical service corporation cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which a medical service corporation determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the medical service corporation; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the contract.

     c.     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.1999, c.106, s.2)

 

     3.    Section 3 of P.L.1999, c.106 (C.17:48E-35.20) is amended to read as follows:

     3.    a.  Every individual and group health service corporation contract that provides hospital or 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 for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the health service corporation cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which the health service corporation determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the health service corporation; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the contract.

     c.     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.1999, c.106, s.3)

 

     4.    Section 4 of P.L.1999, c.106 (C.17B:26-2.1s) is amended to read as follows:

     4.    a.  Every individual health insurance policy that provides hospital or 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 for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the insurer cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which the insurer determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the insurer; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the policy.

     c.     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.1999, c.106, s.4)

 

     5.    Section 5 of P.L.1999, c.106 (C.17B:27-46.1v) is amended to read as follows:

     5.    a.  Every group health insurance policy that provides hospital or 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 benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the policy.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the insurer cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which the insurer determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the insurer; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the policy.

     c.     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.1999, c.106, s.5)

 

     6.    Section 6 of P.L.1999, c.106 (C.17B:27A-7.5) is amended to read as follows:

     6.    a.  Every 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 benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the health benefits plan.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the plan cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which the carrier determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the carrier; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the plan.

     c.     The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

(cf:  P.L.1999,c. 106, s.6)

 

     7.    Section 7 of P.L.1999, c.106 (C.17B:27A-19.7) is amended to read as follows:

     7.    a.  Every 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 benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the health benefits plan.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the plan cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

     b.    Nothing in this section shall be construed to change the manner in which the carrier determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the carrier; or

     (2)   which providers shall be entitled to reimbursement for providing services for mental illness under the health benefits plan.

     c.     The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium.

(cf:  P.L.1999, c.106, s.7)

 

     8.    Section 8 of P.L.1999, c.106 (C.26:2J-4.20) is amended to read as follows:

     8.    a.  Every enrollee agreement 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 [Health and Senior Services] Banking and Insurance, on or after the effective date of this act shall provide health care services for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the agreement.

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Same terms and conditions" means that the health maintenance organization cannot apply different copayments, deductibles or health care services limits to biologically-based mental health care services than those applied to other medical or surgical health care services.

     b.    Nothing in this section shall be construed to change the manner in which a health maintenance organization determines:

     (1)   whether a mental health care service meets the medical necessity standard as established by the health maintenance organization; or

     (2)   which providers shall be entitled to reimbursement or to be participating providers, as appropriate, for mental health services under the enrollee agreement.

     c.     The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the premium.

(cf:  P.L.1999, c.106, s.8)

 

     9.    Section 1 of P.L.1999, c.441 (C.52:14-17.29d) is amended to read as follows:

     1.    As used in this act:

     "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, eating disorders, and pervasive developmental disorder or autism.

     “Eating disorders” means all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.

     "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation or health maintenance organization authorized to issue health benefits plans in this State.

     "Same terms and conditions" means that a carrier cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.

(cf:  P.L.1999, c.441, s.1)

 

     10.  This act shall take effect on the 90th day after enactment and shall apply to contracts, policies, and enrollee agreements issued or renewed on or after that date.


STATEMENT

 

     This bill requires hospital, medical, and health service corporations, individual, small employer and larger group health insurers, health maintenance organizations, and the State Health Benefits Program, to provide insurance coverage for all eating disorders under the same terms and conditions as provided for any other covered sickness.

     In 1999, the Legislature enacted two laws to provide insurance coverage for “biologically-based mental illnesses” under the same terms and conditions as for other covered sicknesses, but the definition of that term did not specifically list eating disorders.  This bill amends the definition of “biologically-based mental illness” to include “eating disorders,” and defines these disorders as “all eating disorders, including but not limited to, anorexia, bulimia, and binge-eating disorder.”

     It is anticipated that this bill will resolve the dispute over whether insurers and health maintenance organizations are required to provide coverage for eating disorders as a biologically-based mental illness.  This bill would clarify that the definition of “biologically-based mental illness” includes all eating disorders.