26:2J-4.20 HMO to provide coverage for biologically based mental illness.
8. a. Every enrollee agreement delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide health care services for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the agreement. "Biologically-based mental illness" means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder, or autism. "Same terms and conditions" means that the health maintenance organization cannot apply different copayments, deductibles, or health care services limits to biologically-based mental health care services than those applied to other medical or surgical health care services.
b.Nothing in this section shall be construed to change the manner in which a health maintenance organization determines:
(1)whether a mental health care service meets the medical necessity standard as established by the health maintenance organization; or
(2)which providers shall be entitled to reimbursement or to be participating providers, as appropriate, for mental health services under the enrollee agreement.
c.The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the premium.
L.1999, c.108, s.8; amended 2012, c.17, s.271.
Section: Previous 26-2j-4.13 26-2j-4.14 26-2j-4.15 26-2j-4.16 26-2j-4.17 26-2j-4.18 26-2j-4.19 26-2j-4.20 26-2j-4.21 26-2j-4.22 26-2j-4.23 26-2j-4.24 26-2j-4.25 26-2j-4.26 26-2j-4.27 Next
Last modified: October 11, 2016