SENATE, No. 297

 

STATE OF NEW JERSEY

 

Introduced Pending Technical Review by Legislative Counsel

 

PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION

 

 

By Senator BENNETT

 

 

An Act requiring health insurance benefits for the treatment of Lyme disease 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, P.L.1973, c.337 (C.26:2J-1 et seq.), P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.).

 

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

 

    1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the contract provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the treatment intravenous therapy shall, if requested by the hospital service corporation, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the hospital service corporation may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the hospital service corporation making the request.

    (2) If requested by the person examined, the hospital service corporation shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

    d. The provisions of this section shall apply to all contracts in


which the hospital service corporation has reserved the right to change the premium.

 

    2. a. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the contract provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the intravenous therapy shall, if requested by the medical service corporation, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the medical service corporation may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the medical service corporation making the request.

    (2) If requested by the person examined, the medical service corporation shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    3. a. No group or individual health service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the contract provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the intravenous therapy shall, if requested by the health service corporation, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the health service corporation may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the health service corporation making the request.

    (2) If requested by the person examined, the health service corporation shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    4. a. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the policy provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease the covered person receiving the intravenous therapy shall, if requested by the insurer, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the insurer may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for1 the treatment of Lyme disease as determined pursuant to this act, shall be borne by the insurer making the request.

    (2) If requested by the person examined, the insurer shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    5. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the policy provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the intravenous therapy shall, if requested by the insurer, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the insurer may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the insurer making the request.

    (2) If requested by the person examined, the insurer shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    6. a. Notwithstanding any provision 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 on or after the effective date of this act unless the health maintenance organization provides health care services to every enrollee for the treatment of Lyme Disease as provided by this section when diagnosed and determined to be medically necessary by the enrollee's physician after making a written evaluation of the enrollee's symptoms, condition and response to treatment. The health care services shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of health care services for intravenous therapy for the treatment of Lyme disease, the enrollee receiving the intravenous therapy shall, if requested by the health maintenance organization, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further health care services for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the enrollee. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the enrollee's primary physician. If the examining physician determines that further health care services for intravenous therapy for the treatment of Lyme disease are not medically necessary, the health maintenance organization may deny the health care services for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the enrollee's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of health care services for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the health maintenance organization making the request.

    (2) If requested by the enrollee examined, the health maintenance organization shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Health care services otherwise eligible for coverage pursuant to this section shall not be denied because such services may be characterized as experimental or investigational in nature.

    d. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.

 

    7. a. No individual health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) shall be issued, executed or renewed in this State on or after the effective date of this act unless the plan provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the intravenous therapy shall, if requested by the carrier, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the carrier may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the carrier making the request.

    (2) If requested by the person examined, the carrier shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    8. a. No small employer health benefits plan subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) shall be issued, executed or renewed in this State on or after the effective date of this act unless the plan provides benefits as provided by this section to each person covered thereunder for expenses incurred in the treatment of Lyme disease when diagnosed and determined to be medically necessary by the covered person's physician after making a written evaluation of that person's symptoms, condition and response to treatment. The benefits shall include, but not be limited to, intravenous therapy as provided in subsection b. of this section.

    b. (1) On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, the covered person receiving the intravenous therapy shall, if requested by the carrier, submit, within a reasonable period of time, to a physical examination by a physician to determine whether further benefits for intravenous therapy for the treatment of Lyme disease are medically necessary. The examination shall be conducted by a physician who has been randomly selected by the Department of Health from a list of physicians established pursuant to paragraph (3) of this subsection and is located within a geographic area that is reasonably accessible to the covered person. Prior to any determination by the examining physician, the examining physician shall discuss his findings with the covered person's primary physician. If the examining physician determines that further benefits for intravenous therapy for the treatment of Lyme disease are not medically necessary, the carrier may deny the benefits for intravenous therapy on or after the fifth day following the determination. The costs of any such requested examination, and the costs for the covered person's intravenous therapy for the treatment for Lyme disease from the date of the request for examination to the date of denial of the continuation of benefits for intravenous therapy for the treatment of Lyme disease as determined pursuant to this act, shall be borne by the carrier making the request.

    (2) If requested by the person examined, the carrier shall deliver to him a copy of every written report concerning an examination rendered by the examining physician pursuant to paragraph (1) of this subsection, at least one of which reports shall set out his findings and conclusions in detail.

    (3) Within 30 days of the enactment date of this act, the Department of Health shall design a simple physician application form and notify all physicians in New Jersey of the application process for inclusion on the Lyme Disease Referral List. To be included on the list a physician shall:

    (a) Be licensed to practice in New Jersey;

    (b) Earn a minimum of 15 continuing medical education credits in Lyme disease each calendar year;

    (c) Conduct an active practice in the delivery of patient services for chronic Lyme disease patients, with at least 10 cases reported annually by the physician meeting the Center for Disease Control's surveillance criteria of 1993; and

    (d) Not be employed by, or receive monetary or other compensation for consulting work from, any health insurance company, hospital, medical or health service corporation or health maintenance organization, or own or have an interest in a home infusion company, at least one year prior to and during the term of inclusion on the list.

    The Department of Health shall, within 30 days of the receipt of the first physician application, compile a list of all physicians who have applied and qualified under this paragraph. The department shall make this list available to the public within 90 days of the enactment of this act. The department shall update the list biannually, and a physician's inclusion on the list shall be reviewed every two years. The department may remove a physician from the list for good cause.

    c. Treatment otherwise eligible for benefits pursuant to this section shall not be denied because such treatment may be characterized as experimental or investigational in nature.

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

 

    9. This act shall take effect on the 90th day after enactment, except that paragraph (3) of subsection b. of sections 1 through 6 of this act shall take effect immediately.

 

 

STATEMENT

 

    This bill requires health insurers, including hospital, medical and health service corporations, commercial insurers and health maintenance organizations, to provide benefits for the treatment of Lyme disease, including intravenous therapy, when diagnosed and determined to be medically necessary by the covered person's physician, after making a written evaluation of that person's symptoms, condition and response to treatment.

    On or after the 56th day of benefits for intravenous therapy for the treatment of Lyme disease, a health insurer may require the insured to be examined by a second physician to determine whether further benefits are medically necessary. The physician must be randomly selected from a Lyme Disease Referral List prepared by the Department of Health pursuant to specific criteria in the bill. If, after an examination, the second physician determines that further benefits for intravenous therapy are not medically necessary, the health insurer may deny benefits for intravenous therapy on or after the fifth day following the determination.

    Treatment otherwise eligible for benefits pursuant to this bill could not be denied because such treatment could be characterized as experimental or investigational in nature.

    Under the bill, the procedures for review of benefits after the 56th day shall specifically apply to benefits for intravenous therapy. Further, the provisions of the bill also shall apply to health benefits plans that are subject to the provisions of the individual and small employer programs pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), respectively.

 

 

 

Requires health insurers to cover Lyme disease.