Part of the opioid abuse legislation quickly signed into law last week by Gov. Chris Christie requires private health insurers in New Jersey to provide expanded inpatient and outpatient treatment of substance abuse disorders at their in-network facilities.

Some are wondering how comprehensive this treatment will be.

“This establishes the time frames insurance companies must follow, so for the first 28 days that someone may need that much time in an inpatient facility, the insurance companies cannot interfere and there’s no prior authorization required,” said state Sen. Joe Vitale, D-Middlesex, a prime sponsor of the legislation and chairman of the Senate Health Committee.

He said after that, “if the patient needs more time, it’s permissible. And if they happen to relapse within the course of a year, they’re also permitted to go back in for additional treatment.”

Vitale says health insurance companies are now going to be required to offer up to six months of treatment during the course of a year.

“No one goes to an inpatient facility for six months, but you could get that much inpatient time in total over the course of a year, and it also includes outpatient treatment as well," he said.

He says the best treatment for someone in recovery is intensive outpatient treatment with some type of medication-assisted treatment, like Suboxone or Vivitrol.

Vitale believes substance addiction treatment should be treated like any other illness.

“If you have a heart attack every year, you’re not turned away. If you’ve come down, God forbid, with cancer and then you have a re-occurrence of that cancer two or three years later, no one denies you,” he said.

According to Vitale, addiction to heroin or opioids is an awful kind of thing that’s hard to imagine, so we need to do everything we can to help those caught in its grips.

“People who really want to clean up and move on with their lives do the best that they can then lo and behold one day they fall back, and some of them die from an overdose,” he said.

“With an addiction it’s an awful thing, it controls every minute of their day. When you’re not in recovery and you’re an active user, it’s all that you think about. It’s something you can’t control.”

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Vitale explained this insurance coverage requirement will increase insurance premiums slightly, but he noted costs for all different types of treatments for many different things are spread out among all of us.

“You know we all pay for it, but it’s $3 more for a policy or $5 more on a policy per year. When you spread out that kind of cost over millions of people, it doesn’t have that much of an effect on your premium,” he said.

According to a summary of the legislation passed and signed by Christie, the law “requires insurers to provide unlimited benefits for inpatient and outpatient treatment of substance use disorders at in-network facilities. The bill further specifies that the services for the treatment of substance use disorders shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise state-approved facilities."

The bill provides that the benefits, for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder, shall be provided when determined medically necessary by the covered person’s physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. If there is no in-network facility immediately available for a covered person, a carrier shall provide necessary exceptions to their network to ensure admission in a treatment facility within 24 hours.

Under the bill, providers of treatment for substance use disorders to persons covered under a covered insurance policy shall not require pre-payment of medical expenses during the 180 days in excess of applicable co-payment, deductible, or co-insurance under the policy. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review.

The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person’s physician. The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in the bill. The bill establishes a process for concurrent review and an appeals process pursuant to the Independent Health Care Appeals Program in the Department of Banking and Insurance.

The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person’s physician. The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services.

The bill specifies that benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the insurer and may be subject to prior authorization or, retrospective review and other utilization management requirements.
The medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health.

The benefits for outpatient prescription drugs used to treat substance abuse disorder shall be provided when determined medically necessary by the covered person’s physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements.

The bill defines a “substance use disorder” as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and includes substance use withdrawal. “Concurrent review” is defined to mean inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans.

The bill provides that the first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange as provided in the bill.”

You can contact reporter David Matthau at David.Matthau@townsquaremedia.com.

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