17:48-6u. Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation
1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be 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 amendatory and supplementary act, unless the contract provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided.
b.A group or individual hospital service corporation contract may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.
c.This section shall apply to all group or individual hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
L.1999,c.49,s.1.
17:48-6v Hospital service corporation to provide coverage for biologically-based mental illness.
1. a. Every individual and group hospital service corporation contract that provides hospital or 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 for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract. "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 hospital service corporation cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits.
b.Nothing in this section shall be construed to change the manner in which a hospital service corporation determines:
(1)whether a mental health care service meets the medical necessity standard as established by the hospital service corporation; or
(2)which providers shall be entitled to reimbursement for providing services for mental illness under the contract.
c.The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
L.1999,c.106,s.1.
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Last modified: October 11, 2016