A2813

ASSEMBLY, No. 2813

STATE OF NEW JERSEY

INTRODUCED MARCH 20, 1997

By Assemblymen FELICE, DORIA and

Assemblywoman Weinberg

An Act concerning health insurance benefits for treatment of mental illness and supplementing P.L.1938, c.366 (C.17:48-1 et seq.), P.L.1940, c.74 (C.17:48A-1 et seq.), P.L.1985, c.236 (C.17:48E-1 et seq.), chapter 26 of Title 17B of the New Jersey Statutes, chapter 27 of Title 17B of the New Jersey Statutes, and P.L.1973, c.337 (C.26:2J-1 et seq.).

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

1. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), every hospital service corporation authorized to do business in this State shall, no later than December 31, 1997, offer for sale individual and group health care contracts in accordance with accepted underwriting standards which provide benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of mental illness or nervous disorders, which benefits are at least equal to the following minimum requirements:

a. In the case of benefits based either upon confinement as an inpatient or partial hospitalization in an acute care or psychiatric licensed hospital, the period of confinement for which benefits shall be payable shall be at least 30 days for inpatient care or 60 days for partial hospitalization in any 12-month benefit period. For the purpose of computing the period for which benefits are payable, each two days of partial hospitalization care shall reduce by one day the 30 days available for inpatient care, and each day of inpatient care shall reduce by two days the 60 days available for partial hospitalization care. Each day of confinement as an inpatient or each two days of partial hospitalization shall reduce by one day the total days available for all other illnesses during any one 12-month benefit period. For the purpose of this section, "partial hospitalization" means continuous treatment for at least three hours, but not more than 12 hours in any 24-hour period.

b. In the case of outpatient benefits for treatment of mental illness or nervous disorders, the benefits shall at least cover services equal to an aggregate benefit of $800 over a 12-month benefit period.

c. The contract may provide for a copayment requirement for mental illness or nervous disorders benefits but that copayment requirement shall not be greater than 50%.

d. The contract may establish a deductible requirement for mental illness or nervous disorders benefits but the deductible amount shall not be greater than the deductible amount for any other sickness benefits provided in the contract.

e. The contract may limit the benefits required in this section to coverage for treatment of clinically significant mental illnesses recognized by a standard psychiatric diagnostic manual, in accordance with rules and regulations adopted by the Commissioner of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

2. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), every medical service corporation authorized to do business in this State shall, no later than December 31, 1997, offer for sale individual and group health care contracts in accordance with accepted underwriting standards which provide benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of mental illness or nervous disorders, which benefits are at least equal to the following minimum requirements:

c. The contract may provide for a copayment requirement for mental illness or nervous disorders benefits but that copayment requirement shall not be greater than 50%.

3. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), every health service corporation authorized to do business in this State shall, no later than December 31, 1997, offer for sale individual and group health care contracts in accordance with accepted underwriting standards which provide benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of mental illness or nervous disorders, which benefits are at least equal to the following minimum requirements:

c. The contract may provide for a copayment requirement for mental illness or nervous disorders benefits but that copayment requirement shall not be greater than 50%.

4. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), every individual health insurer authorized to do business in this State shall, no later than December 31, 1997, offer for sale individual health care policies in accordance with accepted underwriting standards which provide benefits to the insured or other person covered thereunder for expenses incurred in connection with the treatment of mental illness or nervous disorders, which benefits are at least equal to the following minimum requirements:

c. The policy may provide for a copayment requirement for mental illness or nervous disorders benefits but that copayment requirement shall not be greater than 50%.

d. The policy may establish a deductible requirement for mental illness or nervous disorders benefits but the deductible amount shall not be greater than the deductible amount for any other sickness benefits provided in the policy.

e. The policy may limit the benefits required in this section to coverage for treatment of clinically significant mental illnesses recognized by a standard psychiatric diagnostic manual, in accordance with rules and regulations adopted by the Commissioner of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

5. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), every group health insurer authorized to do business in this State shall, no later than December 31, 1997, offer for sale health care policies in accordance with accepted underwriting standards which provide benefits to any insured or other person covered thereunder for expenses incurred in connection with the treatment of mental illness or nervous disorders, which benefits are at least equal to the following minimum requirements:

c. The policy may provide for a copayment requirement for mental illness or nervous disorders benefits but that copayment requirement shall not be greater than 50%.

6. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), and notwithstanding any provisions of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health and Senior Services after the effective date of this act unless the health maintenance organization offers health care services to any enrollee for treatment of mental illness or nervous disorders pursuant to this act.

The Commissioner of Health and Senior Services shall adopt rules and regulations in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) which establish the following minimum requirements for services for treatment of mental illness and nervous disorders provided by health maintenance organizations:

a. In the case of services based either upon confinement as an inpatient or partial hospitalization in an acute care or psychiatric licensed hospital, the period of confinement for which services shall be rendered shall be at least 30 days for inpatient care or 60 days for partial hospitalization in any 12-month service period. For the purpose of computing the period for which services are rendered, each two days of partial hospitalization care shall reduce by one day the 30 days available for inpatient care, and each day of inpatient care shall reduce by two days the 60 days available for partial hospitalization care. Each day of confinement as an inpatient or each two days of partial hospitalization may reduce by one day the total days available for all other illnesses during any one 12-month service period. For the purpose of this section, "partial hospitalization" means continuous treatment for at least three hours, but not more than 12 hours, in any 24-hour period.

b. In the case of outpatient services for treatment of mental illness or nervous disorders, the services shall at least cover services equal to an aggregate benefit of $800 over a 12-month period.

c. The health maintenance organization may provide for a copayment requirement for mental illness or nervous disorders services but that copayment requirement shall not be greater than 50%.

d. The health maintenance organization may establish a deductible requirement for mental illness or nervous disorders services but the deductible amount shall not be greater than the deductible amount for any other sickness services provided by the health maintenance organization.

e. The health maintenance organization may limit the services required in this act to coverage for treatment of clinically significant mental illnesses recognized by a standard psychiatric diagnostic manual, in accordance with rules and regulations adopted by the Commissioner of Health and Senior Services.

7. Sections 1 through 5 of this act shall take effect immediately and section 6 shall take effect on the 90th day following the date of enactment.

STATEMENT

This bill requires hospital, medical and health service corporations, commercial insurers, and health maintenance organizations to offer in all contracts and policies, no later than December 31, 1997, benefits for the treatment of mental illness and nervous disorders. The bill also establishes minimum benefit levels for these benefits. The requirement to offer the benefits would not apply to individual and small employer health benefits plans established pursuant to P.L.1992, c.161 and P.L.1992, c.162, respectively.

The bill requires that the benefits provide for at least 30 days of inpatient hospital care or 60 days of partial hospitalization within a 12-month benefit period. Two partial hospitalization days shall be equal to one inpatient hospitalization day and the total number of days used for this benefit shall be deducted from the total number of days available for all sickness.

The bill also requires that at least the equivalent of $800 of outpatient benefits within a 12-month benefit period be provided and states that there may be a copayment requirement of up to 50% and a deductible requirement, but the deductible must not be greater than the deductible for any other covered sickness.

Finally, to ensure that the required benefits under this bill are used for the treatment of illness, the bill permits carriers to limit coverage to the treatment of clinically significant mental illness recognized by a standard psychiatric diagnostic manual as prescribed by the Commissioner of Banking and Insurance.

Requires health insurers to offer benefits for treatment of mental illness.