17:48E-35.20 Health service corporation to provide coverage for biologically-based mental illness.
3.a. Every individual and group health service corporation contract that provides hospital or 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 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 health 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 the health service corporation determines:
(1)whether a mental health care service meets the medical necessity standard as established by the health 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 health service corporation has reserved the right to change the premium.
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Last modified: October 11, 2016