SENATE, No. 1966

STATE OF NEW JERSEY

217th LEGISLATURE

 

INTRODUCED MARCH 14, 2016

 


 

Sponsored by:

Senator  CHRISTOPHER "KIP" BATEMAN

District 16 (Hunterdon, Mercer, Middlesex and Somerset)

 

 

 

 

SYNOPSIS

     Requires certain health benefits coverage for diagnosing and treating autism and other developmental disabilities.

 

CURRENT VERSION OF TEXT

     As introduced.

  


An Act requiring certain health benefits coverage for the diagnosis and treatment of autism and other developmental disabilities and amending P.L.2009, c.115.

 

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

 

     1.    Section 1 of P.L.2009, c.115 (C.17:48-6ii) is amended to read as follows:

     1.    Notwithstanding any other provision of law to the contrary, every hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The hospital service corporation shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the hospital service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the hospital service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a hospital service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the hospital service corporation to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The hospital service corporation may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the hospital service corporation and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person. 

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the hospital service corporation of the continued medical necessity of the specified therapies and interventions.

     h.    The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals. The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.1)

 

     2.    Section 2 of P.L.2009, c.115 (C.17:48A-7ff) is amended to read as follows:

     2.    Notwithstanding any other provision of law to the contrary, every medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The medical service corporation shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the medical service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the medical service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a medical service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the medical service corporation to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The medical service corporation may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the medical service corporation and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the medical service corporation of the continued medical necessity of the specified therapies and interventions.

     h.    The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals. The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.2)

 

     3.    Section 3 of P.L.2009, c.115 (C.17:48E-35.33) is amended to read as follows:

     3.    Notwithstanding any other provision of law to the contrary, every health service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The health service corporation shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the health service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the health service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a health service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the health service corporation to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The health service corporation may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the health service corporation and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the health service corporation of the continued medical necessity of the specified therapies and interventions.

     h.    The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.3)

 

     4.    Section 4 of P.L.2009, c.115 (C.17B:26-2.1cc) is amended to read as follows:

     4.    Notwithstanding any other provision of law to the contrary, every individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the insured's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the insured is under 21 years of age and the insured's primary diagnosis is autism or social communication disorder, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection. 

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The insurer may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the insurer and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.

     h.    The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions

classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.4)

 

     5.    Section 5 of P.L.2009, c.115 (C.17B:27-46.1ii) is amended to read as follows:

     5.    Notwithstanding any other provision of law to the contrary, every group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the insured's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the insured is under 21 years of age and the insured's primary diagnosis is autism or social communication disorder, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The insurer may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the insurer and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.     

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions.

     h.    The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.5)

     6.    Section 6 of P.L.2009, c.115 (C.17B:27A-7.16) is amended to read as follows:

     6.    Notwithstanding any other provision of law to the contrary, an individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The carrier shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The carrier may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the carrier and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

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

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.6)

 

     7.    Section 7 of P.L.2009, c.115 (C.17B:27A-19.20) is amended to read as follows:

     7.    Notwithstanding any other provision of law to the contrary, a small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, renewed, or approved for issuance or renewal in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1)  The carrier shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the carrier shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the carrier shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the health benefits plan, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a health benefits plan that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a carrier shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The carrier may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the carrier and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

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

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.7)

 

     8.    Section 8 of P.L.2009, c.115 (C.26:2J-4.34) is amended to read as follows:

     8.    Notwithstanding any other provision of law to the contrary, a health maintenance organization enrollee agreement that provides health care services and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section.

     a.    (1) The health maintenance organization shall provide coverage for health care services for screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for health care services pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the enrollee's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the health maintenance organization shall provide coverage for medically necessary occupational therapy, physical therapy, and speech therapy services, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the enrollee is under 21 years of age and the enrollee's primary diagnosis is autism or social communication disorder, the health maintenance organization shall provide coverage for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the coverage provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that an enrollee may make to a provider of behavioral interventions.

     (2)  The coverage provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum coverage amount for an enrollee in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum coverage amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum coverage amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, a health maintenance organization shall not be precluded from providing a coverage amount for an enrollee in any calendar year that exceeds the coverage amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the health maintenance organization to appropriately provide coverage for health care services, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The health maintenance organization may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the health maintenance organization and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting coverage for health care services otherwise available to an enrollee.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the health maintenance organization of the continued medical necessity of the specified therapies and interventions.

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

     i.     An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     j.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.8)

 

     9.    Section 9 of P.L.2009, c.115 (C.52:14-17.29p) is amended to read as follows:

     9.    Notwithstanding any other provision of law to the contrary, the State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage pursuant to the provisions of this section.

     a.    (1) The contract shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the contract shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the contract shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a)  The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, the commission shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The carrier may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the carrier and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

     h.    An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     i.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

(cf:  P.L.2009, c.115, s.9)

 

     10.  Section 10 of P.L.2009, c.115 (C.52:14-17.46.6b) is amended to read as follows:

     10.  Notwithstanding any other provision of law to the contrary, the School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage pursuant to the provisions of this section.

     a.    (1) The contract shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability, including, but not limited to, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     (2)  Practitioners shall use the DSM IV-TR when rendering an autism diagnosis under this section, but an obligation to provide coverage for expenses pursuant to this section shall be required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or after January 1, 2000.

     b.    When the covered person's primary diagnosis is autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability, the contract shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan.  Coverage of these therapies shall not be denied on the basis that the treatment is not restorative or on the basis of any other exclusionary or otherwise limiting language.

     c.    When the covered person is under 21 years of age and the covered person's primary diagnosis is autism or social communication disorder, the contract shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan and as administered directly by, or under the supervision of, a practitioner, subject to the provisions of this subsection.

     (1)  Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions.

     (2)  The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative.

     (3)  (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000.

     (b)  Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated.

     (c)   The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated.

     (d)  Notwithstanding the provisions of this paragraph to the contrary, the commission shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph.

     d.    The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the carrier to appropriately provide benefits, including, but not limited to:  a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating [physician's] practitioner’s signature.  The carrier may only request an updated treatment plan once every six months from the treating [physician] practitioner to review medical necessity, unless the carrier and the treating [physician] practitioner agree that a more frequent review is necessary due to emerging clinical circumstances.

     e.    The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person.

     f.     The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share.

     g.    The coverage required under this section may be subject to utilization review, including periodic review, by the carrier of the continued medical necessity of the specified therapies and interventions.

     h.    An attorney’s fees and costs shall be awarded in favor of a successful claimant alleging failure to comply with the provisions of this section.

     i.     As used in this section:

     “Autism” means any one of the several conditions classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), including: autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome, to the extent that the condition is comorbid with pervasive developmental disorder; Rett’s disorder, to the extent that the condition is comorbid with pervasive developmental disorder; autism spectrum disorder; and any equivalent conditions as classified under any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases, Clinical Modification (ICD-CM) published on or after January 1, 2000.

     “Central auditory processing disorder” means a disorder in the perceptual processing of auditory information in the central nervous system as demonstrated by poor performance in one or more of the following abilities or skills: sound localization and lateralization; auditory discrimination; auditory pattern recognition; temporal aspects of audition, including temporal integration, temporal discrimination, temporal ordering, and temporal masking; auditory performance in competing acoustic signals; and auditory performance with degraded acoustic signals.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Childhood apraxia of speech” means a neurological childhood speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits.  The disorder may occur as a result of known neurological impairment, in association with complex neurobehavioral disorders of known or unknown origin, or as an idiopathic neurogenic speech sound disorder.  The core impairment in planning or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.  The disorder includes conditions classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound disorder in any version of the DSM or ICD-CM published on or after January 1, 2000, and any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Practitioner” means a physician, psychologist, or other health care professional licensed pursuant to Title 45 of the Revised Statutes who is qualified by training to make a diagnosis of autism, central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, social communication disorder, or another developmental disability.  For the purposes of this act, “practitioner” shall also include an individual credentialed by the Behavior Analyst Certification Board as a Board Certified Behavior Analyst or as a Board Certified Behavior Analyst-Doctoral.

     “Sensory processing disorder” means a condition characterized by one or more of the following symptoms that impair daily routines or roles: sensory modulation disorder, defined as difficulty regulating responses to sensory input or as behavior that is not graded relative to the degree, nature, or intensity of the sensory information and including, but not limited to, sensory over-responsivity, sensory under-responsivity, and sensory craving; sensory discrimination disorder, defined as difficulty interpreting qualities of sensory stimuli or perceiving similarities and differences among stimuli and including, but not limited to, sensory discrimination disorder subtypes affecting the visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive sensory systems; and sensory-based motor disorder, defined as a sensory-based impairment of postural or motor planning abilities including, but not limited to, the sensory-based motor disorder subtypes of postural disorder, which involves difficulties with core motor functions and balance, and motor planning disorder, which involves difficulties with the ideation, sequencing, and execution of novel motor actions.  Sensory processing disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1, 2000.

     “Social communication disorder” means a condition characterized by the following symptoms that are present from early childhood and that result in functional limitations in effective communication, social participation, academic achievement, or occupational performance: persistent difficulties in pragmatics or the social uses of verbal and nonverbal communication in naturalistic contexts, which affect the development of social reciprocity and social relationships and which cannot be explained by low abilities in the domains of word structure and grammar or general cognitive ability; persistent difficulties in the acquisition and use of spoken language, written language, or other modalities of language for narrative, expository, and conversational discourse; and the absence of restricted and repetitive patterns of behavior, interests, or activities, thereby ruling out an autism diagnosis.  The disorder includes any equivalent conditions classified under any version of the DSM or ICD-CM published on or after January 1,

2000.

(cf:  P.L.2009, c.115, s.10)

 

     11.  This act shall take effect on the first day of the seventh month next following the date of enactment and shall apply to all policies and contracts issued or renewed on or after the effective date.

 

 

STATEMENT

 

     This bill defines “autism” and adds certain requirements concerning health benefits coverage for autism and other developmental disabilities. The bill also adds requirements concerning health benefits coverage for central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.

     The bill amends P.L.2009, c.115, which requires certain health benefits coverage for diagnosing and treating autism and other developmental disabilities, by defining “autism” to include any one of several related conditions commonly classified under pervasive developmental disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). These related conditions include: autism spectrum disorder; autistic disorder; Asperger’s disorder; childhood disintegrative disorder; pervasive developmental disorder not otherwise specified or unspecified pervasive developmental disorder; fragile X syndrome and Rett’s disorder, to the extent that either condition is comorbid with pervasive developmental disorder; and any other equivalent conditions.  The bill also requires that health care practitioners, as defined pursuant to the bill, use the DSM IV-TR to render an autism diagnosis, and that health insurers maintain an individual’s eligibility for health benefits coverage even if an autism diagnosis is rendered under an updated version of the DSM IV-TR.

     The bill newly requires health insurers to provide coverage for occupational therapy, physical therapy, and speech therapy related to treating central auditory processing disorder, childhood apraxia of speech, sensory processing disorder, and social communication disorder.  The bill also newly requires health insurers to provide coverage for applied behavioral analysis interventions related to treating a social communication disorder.

     The insurers and programs to which the provisions of this bill apply include: health, hospital and medical service corporations; commercial individual and group health insurers; health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs; health maintenance organizations; the State Health Benefits Program; and the School Employees’ Health Benefits Program.  The bill requires attorneys’ fees to be awarded under successful claims demonstrating that an insurer or program has failed to comply with the provisions of the bill.