New Jersey § 26:2j-4

§ 26:2j-4.

a. A health maintenance organization contract that provides hospital or medical expense

benefits and is delivered, issued, executed or renewed in this State, 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, 1 shall provide unlimited benefits for inpatient and outpatient treatment of substance

use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by

a licensed physician, licensed psychologist, or licensed psychiatrist and provided

by licensed health care professionals or licensed or certified substance use disorder

providers in licensed or otherwise State-approved facilities, as required by the laws

of the state in which the services are rendered. b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment

of substance use disorder shall be provided when determined medically necessary by

the covered person's physician, psychologist or psychiatrist without the imposition

of any prior authorization or other prospective utilization management requirements. The facility shall notify the health maintenance organization of both the admission

and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, a

health maintenance organization shall provide necessary exceptions to their network

to ensure admission in a treatment facility within 24 hours. c. Providers of treatment for substance use disorder to persons covered under a covered

contract shall not require pre-payment of medical expenses during this 180 days in

excess of applicable co-payment, deductible, or co-insurance under the policy. d. The benefits for outpatient visits shall not be subject to concurrent or retrospective

review of medical necessity or any other utilization management review. e. (1) The benefits for the first 28 days of an inpatient stay during each plan year

shall be provided without any retrospective review or concurrent review of medical

necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of inpatient care shall be subject to

concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted

for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under

concurrent review shall be submitted within the period that was previously approved. No health maintenance organization shall initiate concurrent review more frequently

than at two-week intervals. If a health maintenance organization determines that continued inpatient care in

a facility is no longer medically necessary, the health maintenance organization shall

within 24 hours provide written notice to the covered person and the covered person's

physician of its decision and the right to file an expedited internal appeal of the

determination pursuant to an expedited process pursuant to sections 11 through 13

of P.L.1997, c. 192 ( C.26:2S-11 through 26:2S-13 ) and N.J.A.C.11:24A-3.5 , as applicable. The health maintenance organization shall review and make a determination with respect

to the internal appeal within 24 hours and communicate such determination to the covered

person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered

person's physician have the right to file an expedited external appeal with the Independent

Health Care Appeals Program in the Department of Banking and Insurance pursuant to

sections 11 through 13 of P.L.1997, c. 192 ( C.26:2S-11 through 26:2S-13 ) and N.J.A.C.11:24A-3.6 , as applicable. An independent utilization review organization shall make a determination within

24 hours. If the health maintenance organization's determination is upheld and it is determined

continued inpatient care is not medically necessary, the carrier shall remain responsible

to provide benefits for the inpatient care through the day following the date the

determination is made and the covered person shall only be responsible for any applicable

co-payment, deductible and co-insurance for the stay through that date as applicable

under the policy. The covered person shall not be discharged or released from the inpatient facility

until all internal appeals and independent utilization review organization appeals

are exhausted. For any costs incurred after the day following the date of determination until the

day of discharge, the covered person shall only be responsible for any applicable

cost-sharing, and any additional charges shall be paid by the facility or provider. f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization

services shall be provided without any retrospective review of medical necessity and

medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization

services shall be subject to a retrospective review of the medical necessity of the

services. g. Benefits for inpatient and outpatient treatment of substance use disorder after

the first 180 days per plan year shall be subject to the medical necessity determination

of the health maintenance organization and may be subject to prior authorization or,

retrospective review and other utilization management requirements. h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical

review tool to be designated through rulemaking by the Commissioner of Human Services

in consultation with the Department of Health. i. The benefits for outpatient prescription drugs to treat substance use disorder

shall be provided when determined medically necessary by the covered person's physician,

psychologist or psychiatrist without the imposition of any prior authorization or

other prospective utilization management requirements. j. The first 180 days per plan year of benefits shall be computed based on inpatient

days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient,

shall be deemed inpatient days for the purpose of the visit to day exchange provided

in this subsection. k. Except as stated above, the benefits and cost-sharing shall be provided to the

same extent as for any other medical condition covered under the contract. l . The benefits required by this section are to be provided to all covered persons

with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to

reduce or deny the benefits required by this section. m. The provisions of this section shall apply to those contracts in which the health

maintenance organization has reserved the right to change the premium. n. The Attorney General's Office shall be responsible for overseeing any violations

of law that may result from P.L.2017, c. 28 ( C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the “Administrative

Procedure Act,” P.L.1968, c. 410 ( C.52:14B-1 et seq. ), rules and regulations to implement any of the provisions of P.L.2017, c. 28 ( C.17:48-6nn et al.). o . The provisions of this section shall not apply to a health maintenance organization

contract which, pursuant to a contract between the health maintenance organization

and the Department of Human Services, provides benefits to persons who are eligible

for medical assistance under P.L.1968, c. 413 ( C.30:4D-1 et seq. ), the “Family Health Care Coverage Act,” P.L.2005, c. 156 ( C.30:4J-8 et seq. ), or any other program administered by the Division of Medical Assistance and Health

Services in the Department of Human Services. p. As used in this section: “ Concurrent review ” means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting,

and patient progress, and as appropriate, the discharge plans. “ Substance use disorder ” is as defined by the American Psychiatric Association in the Diagnostic and Statistical

Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include

substance use withdrawal. 1

L.2017, c. 28, eff. May 16, 2017.