Sponsored by:
Senator ROBERT M. GORDON
District 38 (Bergen and Passaic)
SYNOPSIS
Requires certain health benefits plans to provide coverage for behavioral health care services.
CURRENT VERSION OF TEXT
As reported by the Senate Commerce Committee on February 9, 2015, with amendments.
An Act concerning health insurance coverage for behavioral health care services and revising 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] that contract provides benefits to any subscriber or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are 1[prescribed] deemed medically necessary1 by a [doctor of medicine] 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. [Such] Except as provided in subsections c. and d. 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] behavioral health care services 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];
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by]1 [the] 1[The Joint Commission]1 [on Hospital Accreditation]; 1[and]1
(4) Office visits with a
1[physician licensed to practice
medicine and surgery, a licensed psychologist, a licensed clinical
social worker, a certified advanced practice nurse, or a licensed physician
assistant, acting within their lawful scope of practice] health care provider;
and
(5) Treatment at home and community-based service facilities1.
Treatment or [confinement] participation at any facility 1, hospital,1 or office 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] 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider as1 specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,]:1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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] that contract provides benefits to any subscriber or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are 1[prescribed] deemed medically necessary1 by a [doctor of medicine] 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. [Such] Except as provided in subsections c. and d. 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] behavioral health care services 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];
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by]1 [the] 1[The Joint Commission]1 [on Hospital Accreditation]; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or [confinement] participation at any facility 1, hospital,1 or office 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] 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,]:1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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] behavioral health care services when the [treatment is] services are 1[prescribed] deemed medically necessary1 by a [doctor of medicine] 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. [Benefits] Except as provided in subsections c. and d. 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] behavioral health care services 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 or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by]1 [the] 1[The Joint Commission]1 [on Hospital Accreditation]; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or [confinement] participation at any facility 1, hospital,1 or office 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] 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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] that policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are 1[prescribed] deemed medically necessary1 by a [doctor of medicine] 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. [Such] Except as provided in subsections c. and d. 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] behavioral health care services 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];
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by]1 [the] 1[The Joint Commission]1 [on Hospital Accreditation]; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or [confinement] participation at any facility 1, hospital,1 or office 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] 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the policy.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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] that policy provides benefits to any [subscriber] insured or other covered person [covered thereunder] for [expenses incurred in connection with the treatment of alcoholism] behavioral health care services when [such treatment is] those services are 1[prescribed] deemed medically necessary1 by a [doctor of medicine] 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. [Such] Except as provided in subsections c. and d. 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] behavioral health care services 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] ;
[c. Confinement] (3) Participation as an inpatient or outpatient at a licensed, certified, or [state approved] State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by]1 [the] 1[The Joint Commission]1 [on Hospital Accreditation]; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or [confinement] participation at any facility 1, hospital,1 or office 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] 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the policy.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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 behavioral health care services when the services are 1[prescribed] deemed medically necessary1 by a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. Except as provided in subsections c. and d. 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 behavioral health care services 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;
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission]1 ; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or participation at any facility 1, hospital,1 or office shall not preclude further or additional treatment at any other eligible facility 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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 behavioral health care services when the services are 1[prescribed] deemed medically necessary1 by a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. Except as provided in subsections c. and d. 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 behavioral health care services 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;
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission]1 ; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or participation at any facility 1, hospital,1 or office shall not preclude further or additional treatment at any other eligible facility 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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 behavioral health care services when the services are 1[prescribed] deemed medically necessary1 by a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. Except as provided in subsections c. and d. 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 behavioral health care services 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;
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission]1 ; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or participation at any facility 1, hospital,1 or office shall not preclude further or additional treatment at any other eligible facility 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
f. 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 behavioral health care services when the services are 1[prescribed] deemed medically necessary1 by a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the contract.
b. 1[very] Every1 contract shall include benefits for behavioral health care services 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;
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility1[, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission]1 ; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or participation at any facility 1, hospital,1 or office shall not preclude further or additional treatment at any other eligible facility 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
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 behavioral health care services when the services are 1[prescribed] deemed medically necessary1 by a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider1. Except as provided in subsections c. and d. of this section, the benefits shall be provided to the same extent as for any other sickness under the contract.
b. 1[very] Every1 contract shall include benefits for behavioral health care services 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;
(3) Participation as an inpatient or outpatient at a licensed, certified, or State-approved residential treatment facility or behavioral health care facility 1[, under a program which meets minimum standards of care equivalent to those prescribed by The Joint Commission]1 ; 1[and]1
(4) Office visits with a 1[physician licensed to practice medicine and surgery, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] health care provider; and
(5) Treatment at home and community-based service facilities1.
Treatment or participation at any facility 1, hospital,1 or office shall not preclude further or additional treatment at any other eligible facility 1, hospital,1 or office.
c. Notwithstanding any law or regulation to the contrary, the benefits provided pursuant to this section shall not be subject to utilization management review 1[and the only prerequisite or authorization necessary 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, a licensed psychologist, a licensed clinical social worker, a certified advanced practice nurse, or a licensed physician assistant, acting within their lawful scope of practice] or a medical necessity determination other than the medical necessity determination by the health care provider as specified pursuant to subsection a. of this section1.
d. The 1medical necessity1 determination 1[and prescription] by the health care provider1 as specified pursuant to subsection 1[c.] a.1 of this section shall control both the nature and duration of treatment; except that the coverage under this section may be subject to limits relating to the use of participating providers and facilities as provided in the contract.
e. For the purposes of this section 1[,] :1
"behavioral health care services" means procedures or services rendered by a health care provider or health care facility for the treatment of mental illness, emotional disorders, or drug or alcohol abuse.
1“health care provider” means the treating: physician licensed to practice medicine and surgery, licensed psychologist, licensed clinical social worker, certified advanced practice nurse, licensed marriage or family therapist, licensed professional counselor, or licensed physician assistant, acting within their lawful scope of practice.
“medical necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury, consistent with the applicable standard of care, including the evaluation of experimental or investigational services, procedures, drugs or devices.1
11. P.L.1999, c.106 (C.17:48-6v, C.17:48A-7u, C.17:48E-35.20, C.17B:26-2.1s, C.17B:27-46.1v, C.17B:27A-7.5, C.17B:27A-19.7, C.26:2J-4.20 and C.34:11A-15) is repealed.
12. 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.