Bill > A968

Introduced Session

This bill provides for expanded health insurance coverage for the treatment of mental illness and substance-use disorders. Mental Health Coverage: The bill expands the mental health coverage provisions of P.L.1999, c.106 and P.L.1999, c.441 to require health insurers to provide coverage for serious non-biologically-based mental illness. This requirement would apply to: hospital, medical and health service corporations; individual and small employer and large group commercial health insurers; health maintenance organizations; and the State Health Benefits Program. The current statutory mental health "parity" coverage requirement is limited to biologically-based mental illness (a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder, and pervasive developmental disorder or autism). The bill provides as follows: · "Serious non-biologically-based mental illness" is defined to mean a mental or nervous condition that is primarily treated with psychotherapy or psychotropic medication but is not caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the function of the person with the illnesses, including, but not limited to, dysthymic disorder, post-traumatic stress disorder, borderline personality disorder, bulimia, anorexia and other eating disorders, and other illnesses found in the Diagnostic and Statistical Manual of Mental Disorders as determined by regulation of the Commissioner of Banking and Insurance, in consultation with the Commissioner of Health and Senior Services. · The bill clarifies the definition of "same terms and conditions," and makes it consistent with the definition of that term as provided in the sections of the substitute concerning benefits for treatment of alcoholism and other substance-use disorders. The revised definition provides that an insurer cannot apply different copayments, deductibles or benefit limits, "including day or visit limits or annual or lifetime dollar limits," to mental health benefits than the insurer applies to other medical or surgical benefits. · The provisions of P.L.1999, c.106 and P.L.1999, c.441, which provide that the mental health parity requirements in those laws are not to be construed to change the manner in which the carrier determines whether a mental health care service meets the medical necessity standard as established by the carrier, or which providers are entitled to reimbursement for providing services under the policy or contract, would also apply to the expanded mental health coverage in this substitute. · Notwithstanding any other provision of law to the contrary, the coverage required for mental illness may be subject to utilization review as performed by the insurer. · Notwithstanding the provisions of the bill to the contrary: -- The financial requirements applicable to coverage for mental illness are to be no more restrictive than the financial requirements applied to substantially all medical and surgical benefits covered by the policy or contract, including deductibles, copayments, coinsurance, out-of-pocket expenses, and annual and lifetime limits, and the policy or contract may not establish separate cost-sharing requirements that are applicable only with respect to coverage for mental illness; and -- The treatment limitations applicable to mental illness are to be no more restrictive than the treatment limitations applied to substantially all medical and surgical benefits covered by the policy or contract, including limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. Coverage for Treatment of Alcoholism and Other Substance-Use Disorders: The bill also requires health insurers, as well as the State Health Benefits Program, to provide coverage for treatment of alcoholism and other substance-use disorders under the same terms and conditions as for other diseases or illnesses. Specifically, the bill revises the existing statutory requirement to provide coverage for treatment of alcoholism that applies to hospital, medical and health service corporations, commercial health insurers, and the State Health Benefits Program (but currently not to individual and small employer health benefits plans and health maintenance organizations), to add coverage for treatment of other substance-use disorders and to specify the types of benefits that must be covered. The bill extends the requirement to provide coverage for treatment of alcoholism to those health insurers that are not already mandated by State law to provide such coverage, and includes the requirement to provide coverage for treatment of other substance-use disorders. The bill provides as follows: · "Treatment of alcoholism and other substance-use disorders" is defined to include, but not be limited to, any of the following items or services provided for treatment of alcoholism and other substance-use disorders: inpatient or outpatient treatment, including detoxification, screening and assessment, case management, medication management, psychiatric consultations and individual, group, and family counseling, and relapse prevention; non-hospital residential treatment; and prevention services, including health education and individual and group counseling to encourage the reduction of risk factors for alcoholism or other substance-use disorders. · "Same terms and conditions" is defined to mean that the insurer cannot apply different copayments, deductibles or benefit limits, including day or visit limits or annual or lifetime dollar limits, to alcoholism and other substance-use disorder treatment services than those applied to other medical or surgical expense benefits. · All health insurance contracts or policies are to provide the following benefits: -- inpatient or outpatient care in a licensed health care facility; -- treatment at a State-licensed detoxification facility; -- participation as an inpatient at a State-licensed residential facility or as an outpatient in a State-approved outpatient treatment facility that meets minimum standards of care as set forth by the Department of Human Services; and -- treatment provided by a physician or other appropriately trained, licensed health care professional. · Treatment at any facility is not to preclude further or additional treatment at any other eligible facility if the benefit days used do not exceed the total number of benefit days provided for any other disease or illness under the contract or policy. · The provisions of the bill are not to be construed to: -- prohibit an insurer from determining if the treatment of alcoholism and other substance-use disorders is medically necessary; or -- change the manner in which the insurer determines which health care providers are entitled to reimbursement for providing substance-use disorder treatment services under the policy or contract. · Notwithstanding any other provision of law to the contrary, the coverage required for substance-use disorders may be subject to utilization review as performed by the insurer. · Notwithstanding the provisions of the bill to the contrary: -- The financial requirements applicable to coverage for alcoholism and other substance-use disorders are to be no more restrictive than the financial requirements applied to substantially all medical and surgical benefits covered by the policy or contract, including deductibles, copayments, coinsurance, out-of-pocket expenses, and annual and lifetime limits, and the policy or contract may not establish separate cost-sharing requirements that are applicable only with respect to coverage for alcoholism and other substance-use disorders; and -- The treatment limitations applicable to coverage for alcoholism and other substance-use disorders are to be no more restrictive than the treatment limitations applied to substantially all medical and surgical benefits covered by the policy or contract, including limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. Effective Date: The bill takes effect on the 90th day after the date of enactment and applies to health insurance contracts and policies issued or renewed on or after that date, but would remain inoperative until the enactment into law of Assembly Bill No. 2255 of 2008 (Greenwald/Conaway), which is currently pending before the General Assembly.

AI Summary

Committee Categories

Patrick Diegnan (D)*,  Elease Evans (D)*,  Gordon Johnson (D)*,  Albert Coutinho (D),  Linda Greenstein (D),  Valerie Vainieri Huttle (D),  Joan Voss (D),  Connie Wagner (D), 

Introduced, Referred to Assembly Health and Senior Services Committee (on 01/12/2010)