Section 2842 - Equitable health care for substance use disorder treatment1.Purpose. The Legislature recognizes that substance use disorder constitutes a major health problem in the State and in the Nation. The Legislature further recognizes that substance use disorder is a disease that can be effectively treated. As such, substance use disorder warrants the same attention from the health care industry as other serious diseases and illnesses. The Legislature further recognizes that health insurance contracts, at times, fail to provide adequate benefits for the treatment of substance use disorder, which results in more costly health care for treatment of complications caused by the lack of early intervention and other treatment services for persons suffering from substance use disorder. This situation causes a higher health care, social, law enforcement and economic cost to the citizens of this State than is necessary, including the need for the State to provide treatment to some insureds at public expense. To assist the many citizens of this State who suffer from this illness in a more cost-effective way, the Legislature declares that certain health insurance coverage providing benefits for the treatment of the illness of substance use disorder must be included in all group health insurance contracts. [2017, c. 407, Pt. A, §95(AMD).]
2.Definitions. As used in this section, unless the context indicates otherwise, the following terms have the following meanings.A. "Outpatient care" means care rendered by a state-licensed, approved or certified detoxification, residential treatment or outpatient program, or partial hospitalization program on a periodic basis, including, but not limited to, patient diagnosis, assessment and treatment, individual, family and group counseling and educational and support services. [1983, c. 527, §2(NEW).]B. "Residential treatment" means services at a facility that provides care 24 hours daily to one or more patients, including, but not limited to, the following services: room and board; medical, nursing and dietary services; patient diagnosis, assessment and treatment; individual, family and group counseling; and educational and support services, including a designated unit of a licensed health care facility providing any and all other services specified in this paragraph to patients with substance use disorder. [2017, c. 407, Pt. A, §95(AMD).]C. "Treatment plan" means a written plan initiated at the time of admission, approved by a Doctor of Medicine, a Doctor of Osteopathy or a Registered Substance Abuse Counselor employed by a certified or licensed substance use disorder program, including, but not limited to, the patient's medical and substance use disorder history; record of physical examination; diagnosis; assessment of physical capabilities; mental capacity; orders for medication, diet and special needs for the patient's health or safety and treatment, including medical, psychiatric, psychological, social services, individual, family and group counseling; and educational, support and referral services. [RR 2017, c. 2, §9(COR).] [RR 2017, c. 2, §9(COR).]
3.Requirement. Every insurer that issues group health care contracts providing coverage for hospital care to residents of this State shall provide benefits as required in this section to any subscriber or other person covered under those contracts for the treatment of substance use disorder pursuant to a treatment plan. [2017, c. 407, Pt. A, §95(AMD).]
4.Services; providers. Each group contract must provide, at a minimum, for the following coverage, pursuant to a treatment plan:A. Residential treatment at a hospital or free-standing residential treatment center that is licensed, certified or approved by the State; and [2017, c. 407, Pt. A, §95(AMD).]B. Outpatient care rendered by state licensed, certified or approved providers. [1983, c. 527, §2(NEW).] Treatment or confinement at any facility may not preclude further or additional treatment at any other eligible facility, provided that the benefit days used do not exceed the total number of benefit days provided for under the contract.
[2017, c. 407, Pt. A, §95(AMD).]
5.Exceptions. This section does not apply to employee group insurance policies issued to employers with 20 or fewer employees insured under the group policy or to group policies designed primarily to supplement the Civilian Health and Medical Program of the Uniformed Services, as described in the United States Code, Title 10, Section 1072, subsection 4. [2017, c. 407, Pt. A, §95(AMD).]
6.Limits; coinsurance; deductibles. Any policy or contract that provides coverage for the services required by this section may contain provisions for maximum benefits and coinsurance, and reasonable limitations, deductibles and exclusions to the extent that these provisions are not inconsistent with the requirements of this section. [2017, c. 407, Pt. A, §95(AMD).]
7.Notice. At the time of delivery or renewal, the group health insurer shall provide written notification to all individuals eligible for benefits under group policies or contracts of substance use disorder benefits. [2017, c. 407, Pt. A, §95(AMD).]
8.Confidentiality. Substance use disorder treatment patient records are confidential. [2017, c. 407, Pt. A, §95(AMD).]
9.Reports to the Superintendent of Insurance. Every insurer subject to this section shall report its experience for each calendar year beginning with 1984 to the superintendent not later than April 30th of the following year. The report must be in a form prescribed by the superintendent and must include the amount of claims paid in this State for the services required by this section and the total amount of claims paid in this State for group health care contracts, both separated between those paid for inpatient and outpatient services. The superintendent shall compile this data for all insurers in an annual report. [2017, c. 407, Pt. A, §95(AMD).]
10.Application; expiration. The requirements of this section apply to all policies and any certificates or contracts executed, delivered, issued for delivery, continued or renewed in this State on or after January 1, 1984. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date. [2017, c. 407, Pt. A, §95(AMD).]
Amended by 2018, c. 407,§ A-95, eff. 8/1/2018.Amended by 2011, c. 320,§ A-10, eff. 9/28/2011.1981, c. 319, §§2,3 (NEW) . 1983, c. 527, § 2 (RPR) . 1987, c. 480, § 5 (AMD) . 1989, c. 490, § 3 (AMD) .