Coverage for Treatment of Substance Use Disorders

On March 6, 2017, the New Jersey Department of Insurance published Bulletin No. 17-01, which relates to coverage for treatment of substance use disorders. The bulletin relates to a recently-enacted New Jersey law (P.L. 2017, Chapter 28), which provides that the benefits for the first 28 days of an inpatient stay during each plan year must be provided without any prior authorization or retrospective or concurrent review and that medical necessity must be determined by the covered person’s physician. The benefits for inpatient care on the 29th day and thereafter must be subject to concurrent review.

Importantly, the law states that if a carrier determines that continued inpatient care in a facility is no longer medically necessary, the carrier must within 24 hours provide written notice to the covered person and the covered person’s physician of its decision and the right to file an expedited internal appeal of the determination. According to the bulletin, in order to comply with the intent of the notice requirement, carriers must provide that notice within 24 hours to the covered person, the covered person’s physician as well as to the facility providing the services. The notice is meant to enable appropriate handling of a covered person’s treatment and appeal rights.

The bulletin contains no new employer obligations. But employers will want to be aware of the substance use disorder treatment process, including rights to appeal, should any covered employee (or their dependents) have any questions.

Bulletin No. 17-01 »