SENATE, No. 512

STATE OF NEW JERSEY

219th LEGISLATURE

 

PRE-FILED FOR INTRODUCTION IN THE 2020 SESSION

 


 

Sponsored by:

Senator  JOSEPH F. VITALE

District 19 (Middlesex)

Senator  NELLIE POU

District 35 (Bergen and Passaic)

 

 

 

 

SYNOPSIS

Requires health insurers, SHBP, and SEHBP to provide coverage for certain drug regimens for treatment of AIDS or HIV under certain circumstances.

 

CURRENT VERSION OF TEXT

     Introduced Pending Technical Review by Legislative Counsel.

 


An Act concerning health benefits coverage for certain drug regimens and supplementing various parts of the statutory law.

 

     Be It Enacted by the Senate and General Assembly of the State of New Jersey:

 

     1.    a.   A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A hospital service corporation that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the hospital service corporation fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

     e.     This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.

 

     2.    a.     A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating  infectious diseases. 

     b.    A medical service corporation that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the medical service corporation fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

     e.     This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.

 

     3.    a.   A health service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating  infectious diseases. 

     b.    A health service corporation that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the health service corporation fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

     e.     This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.

 

     4.    a.   An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating  infectious diseases. 

     b.    An insurer that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the insurer fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the policy.

     e.     This section shall apply to those policies in which the insurer has reserved the right to change the premium.

 

     5.    a.   A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating  infectious diseases. 

     b.    An insurer that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the insurer fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the policy.

     e.     This section shall apply to those policies in which the insurer has reserved the right to change the premium.

     6.    a.   An individual health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A carrier that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the carrier fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the plan.

     e.     This section shall apply to those plans in which the carrier has reserved the right to change the premium.

 

     7.    a.   A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A carrier that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the carrier fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the plan.

     e.     This section shall apply to those plans in which the carrier has reserved the right to change the premium.

 

     8.    a.   A health maintenance organization contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State, 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 expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A health maintenance organization that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the health maintenance organization fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

     e.     This section shall apply to those contracts for health care services in which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.

 

     9.    a.     The State Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act, shall provide coverage for expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A carrier that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the carrier fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

     10.    a.   The School Employees’ Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act, shall provide coverage for expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV. Coverage shall be provided as follows:

     (1)   Except as provided in paragraph (2) of this subsection, coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which a multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     b.    A carrier that uses a prior authorization process to assess medical necessity with respect to the coverage required by this section shall complete that process within 14 days of the request for authorization. If the carrier fails to complete the prior authorization process in that time period, the request for authorization shall be deemed to be approved.

     c.     As used in this section:

     “AIDS” means acquired immune deficiency syndrome as defined by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

     “HIV” means the human immunodeficiency virus which has been identified as the probable causative agent of AIDS.

     d.    The benefits required by this section shall be provided to the same extent as for any other condition under the contract.

 

     11.    This act shall take effect on the 90th day next following enactment.

 

 

STATEMENT

 

     This bill requires hospital, medical, and health service corporations, commercial individual and group health insurers, health maintenance organizations, and health benefits plans issued pursuant to the New Jersey Individual Coverage and Small Employer Health Benefits Programs, as well as the State Health Benefits Commission and the School Employees’ Health Benefits Commission, to provide health benefits coverage for expenses for prescribed combination antiretroviral drug treatments that are medically necessary for the treatment of AIDS or HIV.

     The bill further specifies that coverage for this treatment shall be required as follows:

     (1)   Coverage shall be required for a single tablet drug regimen in situations in which that regimen is as effective as a multitablet regimen.

     (2)   In situations in which the multitablet regimen, consistent with clinical guidelines and peer-reviewed scientific and medical literature, is clinically equally to, or more effective than, the single tablet drug regimen, and more likely to result in patient adherence, coverage shall be required for the multitablet regimen, provided the peer review of the literature has been performed by a health care provider with experience in treating infectious diseases. 

     The bill requires insurers that use a prior authorization process to assess medical necessity with respect to the coverage required by this bill to complete that process within 14 days of the request for authorization. If the prior authorization process is not completed in that time period, the request for authorization shall be deemed to be approved.