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A1571
ASSEMBLY, No. 1571
STATE OF NEW JERSEY
222nd LEGISLATURE
�
PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION
Sponsored by:
Assemblyman SEAN T. KEAN
District 30 (Monmouth and Ocean)
Co-Sponsored by:
Assemblywoman Flynn and Assemblyman Scharfenberger
SYNOPSIS
���� Requires certain health benefits coverage for
diagnosing and treating autism and other developmental disabilities.
CURRENT VERSION OF TEXT
���� Introduced Pending Technical Review by Legislative
Counsel.
��
An Act
requiring certain health benefits coverage for
the diagnosis and treatment of autism and other developmental disabilities and
amending P.L.2009, c.115.
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� Section 1 of P.L.2009,
c.115 (C.17:48-6ii) is amended to read as follows:
���� 1.��� Notwithstanding any
other provision of law to the contrary, every hospital service corporation
contract that provides hospital and medical expense benefits and is delivered,
issued, executed, or renewed in this State pursuant to P.L.1938, c.366
(C.17:48-1 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.����
(1)
� The
hospital service corporation shall provide coverage for expenses incurred in
screening and diagnosing autism or another developmental disability
, including,
but not limited to, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
or another developmental disability, the hospital service
corporation 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
or on the basis of
any other exclusionary or otherwise limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, the hospital service corporation 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
and
as administered directly by, or under the supervision of, a practitioner
,
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, a hospital service corporation
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 hospital service corporation 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
]
practitioner�s
signature.� The hospital service corporation may only request an updated
treatment plan once every six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the hospital service corporation and the
treating
[
physician
]
practitioner
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 hospital service corporation of the continued medical necessity
of the specified therapies and interventions.
���� h.��� The provisions of this
section shall apply to all contracts in which the hospital service corporation
has reserved the right to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood
apraxia of speech�
means a neurological childhood speech
sound disorder in which the precision and consistency of movements underlying
speech are impaired in the absence of neuromuscular deficits.� The disorder may
occur as a result of known neurological impairment, in association with complex
neurobehavioral disorders of known or unknown origin, or as an idiopathic
neurogenic speech sound disorder.� The core impairment in planning or
programming spatiotemporal parameters of movement sequences results in errors
in speech sound production and prosody.� The disorder includes conditions
classified under phonological disorder in the DSM IV-TR or ICD-9-CM, conditions
classified under speech sound disorder in any version of the DSM or ICD-CM
published on or after January 1, 2000, and any equivalent conditions classified
under any version of the DSM or ICD-CM published on or after January
1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.1)
���� 2.��� Section 2 of P.L.2009,
c.115 (C.17:48A-7ff) is amended to read as follows:
���� 2.��� Notwithstanding any
other provision of law to the contrary, every medical service corporation
contract that provides hospital and medical expense benefits and is delivered,
issued, executed, or renewed in this State pursuant to P.L.1940, c.74
(C.17:48A-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.����
(1)
� The medical
service corporation shall provide coverage for expenses incurred in screening
and diagnosing autism or another developmental disability
, including, but
not limited to, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
or another developmental disability, the medical service
corporation 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
or on the basis of
any other exclusionary or otherwise limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, the medical service corporation 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
and
as administered directly by, or under the supervision of, a practitioner
,
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, a medical service corporation
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 medical service corporation 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
]
practitioner�s
signature.� The medical service corporation may only request an updated
treatment plan once every six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the medical service corporation and the
treating
[
physician
]
practitioner
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 medical service corporation of the continued medical necessity
of the specified therapies and interventions.
���� h.��� The provisions of this
section shall apply to all contracts in which the medical service corporation
has reserved the right to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.2)
���� 3.��� Section 3 of P.L.2009,
c.115 (C.17:48E-35.33) is amended to read as follows:
���� 3.��� Notwithstanding any
other provision of law to the contrary, every health service corporation
contract that provides hospital and medical expense benefits and is delivered,
issued, executed, or renewed in this State pursuant to P.L.1985, c.236
(C.17:48E-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.����
(1)
� The health
service corporation shall provide coverage for expenses incurred in screening
and diagnosing autism or another developmental disability
, including, but
not limited to, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, and social communication disorder
.
����
(2) Practitioners shall use
the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
or another developmental disability, the health service
corporation 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
or on the basis of
any other exclusionary or otherwise limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, the health service corporation 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
and as
administered directly by, or under the supervision of, a practitioner
,
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, a health service corporation
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 health service corporation 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
]
practitioner�s
signature.� The health service corporation may only request an updated
treatment plan once every six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the health service corporation and the
treating
[
physician
]
practitioner
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 health service corporation of the continued medical necessity of
the specified therapies and interventions.
���� h.��� The provisions of this
section shall apply to all contracts in which the health service corporation
has reserved the right to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.3)
���� 4.��� Section 4 of P.L.2009,
c.115 (C.17B:26-2.1cc) is amended to read as follows:
���� 4.��� Notwithstanding any
other provision of law to the contrary, every individual health insurance
policy that provides hospital and medical expense benefits and is delivered,
issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B
of the New Jersey Statutes, 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.����
(1)
� The insurer
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the insured's
primary diagnosis is autism
, central auditory processing disorder, childhood
apraxia of speech, sensory processing disorder, social communication disorder,
or another developmental disability, the insurer 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
or on the basis of any other exclusionary or otherwise limiting
language
.
���� c.���� When the insured is
under 21 years of age and the insured's primary diagnosis is autism
or
social communication disorder
, the insurer 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
and as administered
directly by, or under the supervision of, a practitioner
, 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 policy, but shall not be subject to limits on the number of
visits that an insured 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 an insured 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 policy 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, an insurer shall not be precluded
from providing a benefit amount for an insured 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 insurer 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
]
practitioner�s
signature.� The insurer may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the insurer and the treating
[
physician
]
practitioner
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 an insured.
���� 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 insurer of the continued medical necessity of the specified
therapies and interventions.
���� h.��� The provisions of this
section shall apply to all policies in which the insurer has reserved the right
to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.4)
���� 5.��� Section 5 of P.L.2009,
c.115 (C.17B:27-46.1ii) is amended to read as follows:
���� 5.��� Notwithstanding any
other provision of law to the contrary, every group health insurance policy
that provides hospital and medical expense benefits and is delivered, issued,
executed, or renewed in this State pursuant to chapter 27 of Title 17B of the
New Jersey Statutes, 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.����
(1)
� The insurer
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the insured's
primary diagnosis is autism
, central auditory processing disorder, childhood
apraxia of speech, sensory processing disorder, social communication disorder,
or another developmental disability, the insurer 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
or on the basis of any other exclusionary or otherwise limiting
language
.
���� c.���� When the insured is
under 21 years of age and the insured's primary diagnosis is autism
or
social communication disorder
, the insurer 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
and as administered
directly by, or under the supervision of, a practitioner
, 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 policy, but shall not be subject to limits on the number of
visits that an insured 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 an insured 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 policy 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, an insurer shall not be precluded
from providing a benefit amount for an insured 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 insurer 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
]
practitioner�s
signature.� The insurer may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the insurer and the treating
[
physician
]
practitioner
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 an insured.
���� 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 insurer of the continued medical necessity of the specified
therapies and interventions.
���� h.��� The provisions of this
section shall apply to all policies in which the insurer has reserved the right
to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.5)
���� 6.��� Section 6 of P.L.2009,
c.115 (C.17B:27A-7.16) is amended to read as follows:
���� 6.��� Notwithstanding any
other provision of law to the contrary, an individual health benefits plan that
provides hospital and medical expense benefits and is delivered, issued,
executed, renewed, or approved for issuance or renewal in this State pursuant
to P.L.1992, c.161 (C.17B:27A-2 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.����
(1)
� The carrier
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
or another developmental disability, the carrier 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
or on the basis of any other exclusionary or otherwise
limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, the carrier 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
and as administered
directly by, or under the supervision of, a practitioner
, 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 health benefits plan, 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 health benefits plan 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 carrier 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
]
practitioner�s
signature.� The carrier may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the carrier and the treating
[
physician
]
practitioner
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.
���� h.��� The provisions of this
section shall apply to those health benefits plans in which the carrier has
reserved the right to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.6)
���� 7.��� Section 7 of P.L.2009,
c.115 (C.17B:27A-19.20) is amended to read as follows:
���� 7.��� Notwithstanding any
other provision of law to the contrary, a small employer health benefits plan
that provides hospital and medical expense benefits and is delivered, issued,
executed, renewed, or approved for issuance or renewal in this State pursuant to
P.L.1992, c.162 (C.17B:27A-17 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.����
(1)
� The carrier
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
or another developmental disability, the carrier 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
or on the basis of any other exclusionary or otherwise
limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, the carrier 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
and as administered
directly by, or under the supervision of, a practitioner
, 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 health benefits plan, 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 health benefits plan 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 carrier 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
]
practitioner�s
signature.� The carrier may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the carrier and the treating
[
physician
]
practitioner
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.
���� h.��� The provisions of this
section shall apply to those health benefits plans in which the carrier has
reserved the right to change the premium.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.7)
���� 8.��� Section 8 of P.L.2009,
c.115 (C.26:2J-4.34) is amended to read as follows:
���� 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.����
(1)
The health
maintenance organization shall provide coverage for health care services for
screening and diagnosing autism or another developmental disability
, including,
but not limited to, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for health care services pursuant to this
section shall be required whether an autism diagnosis is rendered under the DSM
IV-TR, the IDC-9-CM, or any other version of the DSM or ICD-CM published on or
after January 1, 2000.
���� b.��� When the enrollee's
primary diagnosis is autism
, central auditory processing disorder, childhood
apraxia of speech, sensory processing disorder, social communication disorder,
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
or on the basis of any other exclusionary or otherwise
limiting language
.
���� c.���� When the enrollee is
under 21 years of age and the enrollee's primary diagnosis is autism
or
social communication disorder
, 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
and as administered
directly by, or under the supervision of, a practitioner
, 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
]
practitioner�s
signature.� The health maintenance organization may only request an updated
treatment plan once every six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the health maintenance organization and the
treating
[
physician
]
practitioner
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.
����
i.���� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
j.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.8)
���� 9.��� Section 9 of P.L.2009,
c.115 (C.52:14-17.29p) is amended to read as follows:
���� 9.��� Notwithstanding any
other provision of law to the contrary, the State Health Benefits Commission
shall ensure that every contract purchased by the commission on or after the
effective date of this act that provides hospital or medical expense benefits
shall provide coverage pursuant to the provisions of this section.
���� a.����
(1)
The contract
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1,
2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
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
or on the basis of any other exclusionary or otherwise
limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, 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
and as administered
directly by, or under the supervision of, a practitioner
, 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
]
practitioner�s
signature.� The carrier may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the carrier and the treating
[
physician
]
practitioner
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.
����
h.��� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
i.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or
activities, thereby ruling out an autism diagnosis. The disorder includes any equivalent
conditions classified under any version of the DSM or ICD-CM published on or
after January 1, 2000.
(cf: P.L.2009, c.115, s.9)
���� 10.� Section 10 of P.L.2009,
c.115 (C.52:14-17.46.6b) is amended to read as follows:
���� 10.� 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 that provides hospital or medical expense
benefits shall provide coverage pursuant to the provisions of this section.
���� a.����
(1)
The contract
shall provide coverage for expenses incurred in screening and diagnosing autism
or another developmental disability
, including, but not limited to, central
auditory processing disorder, childhood apraxia of speech, sensory processing
disorder, and social communication disorder
.
����
(2)�� Practitioners shall
use the DSM IV-TR when rendering an autism diagnosis under this section, but an
obligation to provide coverage for expenses pursuant to this section shall be
required whether an autism diagnosis is rendered under the DSM IV-TR, the IDC-9-CM,
or any other version of the DSM or ICD-CM published on or after January 1, 2000.
���� b.��� When the covered
person's primary diagnosis is autism
, central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, social communication
disorder,
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
or on the basis of any other exclusionary or otherwise
limiting language
.
���� c.���� When the covered person
is under 21 years of age and the covered person's primary diagnosis is autism
or
social communication disorder
, 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
and as administered
directly by, or under the supervision of, a practitioner
, 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
]
practitioner�s
signature.� The carrier may only request an updated treatment plan once every
six months from the treating
[
physician
]
practitioner
to review medical necessity, unless the carrier and the treating
[
physician
]
practitioner
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.
����
h.��� An attorney�s fees
and costs shall be awarded in favor of a successful claimant alleging failure
to comply with the provisions of this section.
����
i.���� As used in this
section:
����
�Autism� means any one of
the several conditions classified under pervasive developmental disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text
Revision (DSM IV-TR) or the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM), including: autistic disorder;
Asperger�s disorder; childhood disintegrative disorder; pervasive developmental
disorder not otherwise specified or unspecified pervasive developmental
disorder; fragile X syndrome, to the extent that the condition is comorbid with
pervasive developmental disorder; Rett�s disorder, to the extent that the
condition is comorbid with pervasive developmental disorder; autism spectrum
disorder; and any equivalent conditions as classified under any version of the Diagnostic
and Statistical Manual of Mental Disorders (DSM) or the International
Classification of Diseases, Clinical Modification (ICD-CM) published on or
after January 1, 2000.
����
�Central auditory
processing disorder� means a disorder in the perceptual processing of auditory
information in the central nervous system as demonstrated by poor performance
in one or more of the following abilities or skills: sound localization and lateralization;
auditory discrimination; auditory pattern recognition; temporal aspects of
audition, including temporal integration, temporal discrimination, temporal
ordering, and temporal masking; auditory performance in competing acoustic
signals; and auditory performance with degraded acoustic signals. The disorder
includes any equivalent conditions classified under any version of the DSM or
ICD-CM published on or after January 1, 2000.
���
����
�Childhood apraxia of speech�
means a neurological childhood speech sound disorder in which the precision and
consistency of movements underlying speech are impaired in the absence of
neuromuscular deficits.� The disorder may occur as a result of known
neurological impairment, in association with complex neurobehavioral disorders
of known or unknown origin, or as an idiopathic neurogenic speech sound
disorder.� The core impairment in planning or programming spatiotemporal
parameters of movement sequences results in errors in speech sound production
and prosody.� The disorder includes conditions classified under phonological
disorder in the DSM IV-TR or ICD-9-CM, conditions classified under speech sound
disorder in any version of the DSM or ICD-CM published on or after January
1, 2000, and any equivalent conditions classified under any version of the DSM
or ICD-CM published on or after January 1, 2000.
����
�Practitioner� means a
physician, psychologist, or other health care professional licensed pursuant to
Title 45 of the Revised Statutes who is qualified by training to make a
diagnosis of autism, central auditory processing disorder, childhood apraxia of
speech, sensory processing disorder, social communication disorder, or another
developmental disability.� For the purposes of this act, �practitioner� shall
also include an individual credentialed by the Behavior Analyst Certification
Board as a Board Certified Behavior Analyst or as a Board Certified Behavior
Analyst-Doctoral.
����
�Sensory processing
disorder� means a condition characterized by one or more of the following
symptoms that impair daily routines or roles: sensory modulation disorder,
defined as difficulty regulating responses to sensory input or as behavior that
is not graded relative to the degree, nature, or intensity of the sensory
information and including, but not limited to, sensory over-responsivity,
sensory under-responsivity, and sensory craving; sensory discrimination
disorder, defined as difficulty interpreting qualities of sensory stimuli or
perceiving similarities and differences among stimuli and including, but not
limited to, sensory discrimination disorder subtypes affecting the visual,
auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and
interoceptive sensory systems; and sensory-based motor disorder, defined as a
sensory-based impairment of postural or motor planning abilities including, but
not limited to, the sensory-based motor disorder subtypes of postural disorder,
which involves difficulties with core motor functions and balance, and motor
planning disorder, which involves difficulties with the ideation, sequencing,
and execution of novel motor actions.� Sensory processing disorder includes any
equivalent conditions classified under any version of the DSM or ICD-CM
published on or after January 1, 2000.
����
�Social communication
disorder� means a condition characterized by the following symptoms that are
present from early childhood and that result in functional limitations in
effective communication, social participation, academic achievement, or
occupational performance: persistent difficulties in pragmatics or the social
uses of verbal and nonverbal communication in naturalistic contexts, which
affect the development of social reciprocity and social relationships and which
cannot be explained by low abilities in the domains of word structure and
grammar or general cognitive ability; persistent difficulties in the
acquisition and use of spoken language, written language, or other modalities
of language for narrative, expository, and conversational discourse; and the
absence of restricted and repetitive patterns of behavior, interests, or �activities,
�thereby �ruling out an autism diagnosis. The
disorder �includes �any� equivalent
�conditions �classified �under any
version of the DSM or ICD-CM
published on or after January 1, 2000.
(cf: P.L.2009, c.115, s.10)
���� 11.� This act shall take
effect on the first day of the seventh month next following the date of
enactment and shall apply to all policies and contracts issued or renewed on or
after the effective date.
STATEMENT
���� This bill defines �autism� and
adds certain requirements concerning health benefits coverage for autism and other
developmental disabilities. The bill also adds requirements concerning health
benefits coverage for central auditory processing disorder, childhood apraxia
of speech, sensory processing disorder, and social communication disorder.
���� The bill amends P.L.2009,
c.115, which requires certain health benefits coverage for diagnosing and
treating autism and other developmental disabilities, by defining �autism� to
include any one of several related conditions commonly classified under
pervasive developmental disorder in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM IV-TR) or the
International Classification of Diseases, Ninth Revision, Clinical Modification
(ICD-9-CM).� These related conditions include: autism spectrum disorder;
autistic disorder; Asperger�s disorder; childhood disintegrative disorder;
pervasive developmental disorder not otherwise specified or unspecified
pervasive developmental disorder; fragile X syndrome and Rett�s disorder, to
the extent that either condition is comorbid with pervasive developmental
disorder; and any other equivalent conditions.� The bill also requires that
health care practitioners, as defined pursuant to the bill, use the DSM IV-TR
to render an autism diagnosis and requires that health insurers maintain an
individual�s eligibility for health benefits coverage even if an autism
diagnosis is rendered under an updated version of the DSM IV-TR.
���� The bill newly requires health
insurers to provide coverage for occupational therapy, physical therapy, and
speech therapy related to treating central auditory processing disorder,
childhood apraxia of speech, sensory processing disorder, and social communication
disorder.� The bill also newly requires health insurers to provide coverage for
applied behavioral analysis interventions related to treating social
communication disorder.
���� The insurers and programs to
which the provisions of this bill apply include:� health, hospital and medical
service corporations; commercial individual and group health insurers; health
benefits plans issued pursuant to the New Jersey Individual Health Coverage and
Small Employer Health Benefits Programs; health maintenance organizations; the
State Health Benefits Program; and the School Employees� Health Benefits
Program.� The bill requires attorneys� fees to be awarded under successful
claims demonstrating that an insurer or program has failed to comply with the
provisions of the bill.