N.J. Admin. Code § 11:4-57.3 - Exclusions and benefit limits

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Notwithstanding the applicability of such exclusions to persons with physical illness, carriers shall not apply any exclusion in a health insurance policy or health maintenance organization contract to deny benefits for services or supplies that are medically necessary for the treatment of covered persons with biologically-based mental illness, so long as such services or supplies are not experimental or investigational. This proscription shall include but not be limited to:
1. Exclusions for the treatment of chronic conditions;
2. Exclusions for physical, speech and occupational therapy that is non-restorative (that is, that does not restore previously possessed function, skill or ability);
3. Exclusions for services rendered after a fixed period of time has elapsed from an injury, procedure or the onset of illness;
4. Exclusions for the treatment of developmental disorders or developmental delay;
5. Exclusions for therapy on a long-term basis;
6. Exclusions for the treatment of behavioral problems; and
7. Exclusions for the treatment of learning disabilities.
(b) Subject to (a) above, carriers may apply preauthorization requirements, to treatment of biologically-based mental illness only if those requirements are applicable to treatments of physical illnesses and consistent with the requirements of the Federal Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) part of Public Law 110-343, and further:
1. Visit limits are prohibited; and
2. Preauthorization requirements:
i. A carrier shall not require preauthorization of all services to treat biologically-based mental illness, this means that blanket preauthorization is not permitted.
ii. Preauthorization of particular services for the treatment of biologically-based mental illness is permitted only if consistent with MHPAEA.


N.J. Admin. Code § 11:4-57.3
Amended by 51 N.J.R. 618(a), effective 5/6/2019

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