New Jersey § 52:14-17

§ 52:14-17.

Notwithstanding any other provision of law to the contrary, the School Employees'

Health Benefits Commission shall ensure that every contract purchased by the commission

on or after the effective date of this act 1 that provides hospital or medical expense benefits shall provide coverage pursuant

to the provisions of this section. a. The contract shall provide coverage for expenses incurred in screening and diagnosing

autism or another developmental disability. b. When the covered person's primary diagnosis is autism or another developmental

disability, the contract shall provide coverage for expenses incurred for medically

necessary occupational therapy, physical therapy, and speech therapy, 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 covered person is under 21 years of age and the covered person's primary

diagnosis is autism, the contract shall provide coverage for expenses incurred 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 benefits 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 a covered person may make to a provider of behavioral interventions. (2) The benefits provided pursuant to this subsection shall not be denied on the basis

that the treatment is not restorative. (3)(a) The maximum benefit amount for a covered person in any calendar year through

2011 shall be $36,000. (b) Commencing on January 1, 2012, the maximum benefit 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 benefit 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, the commission

shall not be precluded from providing a benefit amount for a covered person in any

calendar year that exceeds the benefit 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 carrier to appropriately provide benefits,

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 carrier may only request an updated treatment plan once every six months from

the treating physician to review medical necessity, unless the carrier 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 benefits otherwise available to a covered person. 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 carrier of the continued medical necessity of the

specified therapies and interventions. 1

L.2009, c. 115, eff. Feb. 9, 2010.