Sponsored by:
Assemblywoman ELIANA PINTOR MARIN
District 29 (Essex and Hudson)
Assemblywoman ELLEN J. PARK
District 37 (Bergen)
SYNOPSIS
Requires prescription drug coverage for serious mental illness without prior authorization or utilization management, including step therapy.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning utilization management, amending P.L.2019, c.58, and supplementing P.L.1968, c.413 (30:4D-1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 11 of P.L.2019, c.58 (C.26:2S-10.8) is amended to read as follows:
11. a. For the purposes of this section:
"Benefit limits" includes both quantitative treatment limitations and non-quantitative treatment limitations.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State or any entity contracted to administer health benefits in connection with the State Health Benefits Program or School Employees' Health Benefits Program.
"Classification of benefits" means the classifications of benefits found at 45 C.F.R. 146.136(c)(2)(ii)(A) and 45 C.F.R. s.146.136(c)(3)(iii).
"Department" means the Department of Banking and Insurance.
"Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders.
"Non-quantitative treatment limitations" or "NQTL" means processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs shall include, but shall not be limited to:
(1) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
(2) Formulary design for prescription drugs;
(3) For plans with multiple network tiers, such as preferred providers and participating providers, network tier design;
(4) Standards for provider admission to participate in a network, including reimbursement rates;
(5) Plan methods for determining usual, customary, and reasonable charges;
(6) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, also known as fail-first policies or step therapy protocols;
(7) Exclusions based on failure to complete a course of treatment;
(8) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage;
(9) In and out-of-network geographic limitations;
(10) Limitations on inpatient services for situations where the participant is a threat to self or others;
(11) Exclusions for court-ordered and involuntary holds;
(12) Experimental treatment limitations;
(13) Service coding;
(14) Exclusions for services provided by a licensed professional who provides mental health condition or substance use disorder services;
(15) Network adequacy; and
(16) Provider reimbursement rates.
Serious mental illness means the following psychiatric illnesses as defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders:
(1) bipolar disorders including hypomanic, manic, depressive, and mixed;
(2) depression in childhood and adolescence;
(3) major depressive disorders, whether a single episode or recurrent;
(4) obsessive compulsive disorders;
(5) paranoid and other psychotic disorders;
(6) schizo-affective disorders including bipolar and depressive; and
(7) schizophrenia.
"Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders.
b. A carrier shall approve a request for an in-plan exception if the carrier's network does not have any providers who are qualified, accessible and available to perform the specific medically necessary service. A carrier shall communicate the availability of in-plan exceptions:
(1) on its website where lists of network providers are displayed; and
(2) to beneficiaries when they call the carrier to inquire about network providers.
c. A carrier that provides hospital or medical expense benefits through individual or group contracts shall submit an annual report to the department on or before March 1. The annual report shall contain, to the extent that the commissioner determines practicable, the following information:
(1) A description of the process used to develop or select the medical necessity criteria for mental health benefits, the process used to develop or select the medical necessity criteria for substance use disorder benefits, and the process used to develop or select the medical necessity criteria for medical and surgical benefits;
(2) Identification of all NQTLs that are applied to mental health benefits, all NQTLs that are applied to substance use disorder benefits, and all NQTLs that are applied to medical and surgical benefits, including, but not limited to, those listed in subsection a. of this section;
(3) The results of an analysis that demonstrates that for the medical necessity criteria described in paragraph (1) of this subsection and for selected NQTLs identified in paragraph (2) of this subsection, as written and in operation, the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and selected NQTLs to mental health condition and substance use disorder benefits are comparable to, and are no more stringently applied than the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and selected NQTLs, as written and in operation, to medical and surgical benefits. A determination of which selected NQTLs require analysis will be determined by the department; at a minimum, the results of the analysis shall entail the following, provided that some NQTLs may not necessitate all of the steps described below:
(a) identify the factors used to determine that an NQTL will apply to a benefit, including factors that were considered but rejected;
(b) identify and define the specific evidentiary standards, if applicable, used to define the factors and any other evidentiary standards relied upon in designing each NQTL;
(c) provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to design each NQTL, as written, for mental health and substance use disorder benefits are comparable to and applied no more stringently than the processes and strategies used to design each NQTL as written for medical and surgical benefits;
(d) provide the comparative analyses, including the results of the analyses, performed