Section: Health maintenance organization to provide benefits for treatment of autism or other developmental disability.
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. The health maintenance organization shall provide coverage for health care services for screening and diagnosing autism or another developmental disability.
b. When the enrollee's primary diagnosis is autism 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.
c. When the enrollee is under 21 years of age and the enrollee's primary diagnosis is autism, 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, 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 signature. The health maintenance organization may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the health maintenance organization and the treating physician 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.
L.2009, c.115, s.8.
We hope you find our tools helpful, please visit www.thelegalassistant.com for further information on our other free legal tools and products including LPO compliant legal case management software.