26:2J-4.20 HMO to provide coverage for mental health conditions, substance use disorders; collaborative care model.
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/nj/title-26/chapter-2j/26-2j-4-20·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
8. a.
(1)Every enrollee agreement 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 health care services for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the agreement and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3).
Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model.
(2)As used in this section:
"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.
"Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology
(CPT)codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented:
(a)99492 - Initial psychiatric collaborative care management;
(b)99493 - Subsequent psychiatric collaborative care management; and
(c)99494 - Initial or subsequent psychiatric collaborative care management, additional time.
"Same terms and conditions" means that the health maintenance organization cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or health care services limits to mental health condition and substance use disorder services than those applied to substantially all other medical or surgical health care services.
"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. (Deleted by amendment, P.L.2019, c.58)
c. The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the premium.
d. Nothing in this section shall reduce the requirement for a health maintenance organization to provide benefits pursuant to section 8 of P.L.2017, c.28 (C.26:2J-4.39).
L.1999, c.106, s.8; amended 2012, c.17, s.271; 2019, c.58, s.8; 2022, c.33, s.8.