Landmark: A Visionary And Dramatic Step Forward!

Completing a challenge issued to the legislature in his State of the State address last month and continuing his most aggressive, innovative campaign in the nation against drug addiction, New Jersey Governor Chris Christie signed into law today his life-saving healthcare reform that will guarantee insurance coverage for people to access immediate treatment and to limit initial opioid prescriptions. S-3 addresses several clear causes of opioid addiction and relapse.

This new law provides the greatest access to treatment in the country, making New Jersey the only state in which people with insurance cannot be retroactively charged for six months of necessary addiction treatment. Upon most-recent review, two states have adopted a remotely similar framework as set forth in S-3, New York and Massachusetts, with New York providing a 14-day period of treatment without utilization management and allowing for retroactive denial of coverage starting from the first day of treatment.

This new law also establishes in New Jersey the country’s strongest maximum limit of five days’ worth of prescribed opioid pills after rigorous precautions to keep them out of the hands of children and the vulnerable. Prescribers in New Jersey must undertake a myriad of safeguards, including notification of the risks of addiction, entering into pain management agreements, and inquiring about patients’ medical history and proclivity for abuse or addiction. Most states allow opioid prescriptions to last seven days or longer.

WATCH:  Governor Christie: Treatment And Hope First, No More Insurance Denials

GOVERNOR CHRISTIE: “No more pre-approvals. No more medical necessity reviews prior to admission by an insurance company bureaucrat. No more denials that can cost lives. Treatment first. Hope first. Denials last.” (State of the State, 1/10/17)

INCREASING ACCESS TO CARE. 
This new law provides that all New Jersey regulated commercial insurance plans and the State Health Benefits Programs will provide unlimited benefits for inpatient and outpatient treatment for substance use disorder at in-network facilities provided the treatment is prescribed by a licensed physician and the services are provided by licensed or certified health care professionals.

• The first 180 days of each plan year of inpatient and outpatient treatment for substance use disorder will be provided without requiring prior authorization or any other prospective utilization management requirement. If there is no in-network facility immediately available, a carrier must provide a facility within 24 hours. 
• Providers or facilities are prohibited under the bill from seeking any pre-payment beyond allowable co-payments, deductibles or co-insurance. 

Specifically for outpatient services, carriers are prohibited from undertaking any prior authorization or medical necessity review for the entire 180 days of service. Under the bill, an outpatient treatment day is considered half an in-patient treatment day. Therefore, a person receiving only outpatient treatment could receive 360 treatments in a plan year without any interference from their carrier.

For in-patient services, no utilization management can take place for the first 28 days of an inpatient stay. Thereafter, a carrier can conduct utilization management reviews every two weeks.

• If a carrier determines that continued in-patient treatment is not medically necessary, a covered person can appeal internally, and if the carrier’s finding is affirmed, the covered person can appeal to the Independent Health Care Appeals Program in the Department of Banking and Insurance.

• If, after all the foregoing appeals are exhausted, a carrier’s determination regarding lack of medical necessity is affirmed, a covered person can be discharged, but can then undergo outpatient treatment without any carrier interference for the remainder of the 180 day period. Additionally, the carrier must provide coverage for the entire period for which appeals are pending. If a person stays after coverage has expired, the provider is responsible for the costs of treatment. At no time will any covered person pay more than their co-payment, deductible or co-insurance.

• All medical necessity reviews conducted by carriers related to substance abuse treatment must utilize an evidence-based and peer reviewed clinical review tool that will be approved by the Department of Human Services.

• In addition to in-person treatments, all prescription drugs used to treat substance abuse disorder shall be covered by a carrier without prior authorization or utilization management review.

•  The law explicitly provides that a person with a co-diagnosis of substance abuse disorder and another related or unrelated diagnosis is required to receive all protections under the law. The law confirms that parity is required by providing that all benefits and cost-sharing for substance abuse disorders are to be provided to the same extent as any other covered medical condition.

• Finally, to protect against potential waste and abuse, the law provides that the Attorney General’s Office will be tasked with investigating and prosecuting any violations of the law.

LIMITING OPIOID PRESCRIPTIONS. 
This new law also creates a framework to prevent the excessive and unnecessary prescribing of opioids. Under the law, a practitioner is not permitted to issue an initial prescription for an opioid drug in a quantity exceeding a five-day supply for treatment of acute pain. Prior to issuing such an initial prescription, a practitioner shall:

• Discuss with the patient the risks associated with the drug, including risks of addiction and overdose;
• Explain the reasons why the prescription is necessary;
• Set forth available alternative treatments;
• Take and document the results of a thorough medical history;
• Conduct, as appropriate, a physical examination;
• Develop a treatment plan focused on the patient’s pain;
• Access relevant information from the Prescription Monitoring Program.

On the fourth day of an initial prescription a practitioner may, after consultation with the patient, issue a subsequent prescription for the opioid drug. In order to do so, the practitioner must determine that the subsequent prescription is: (i) necessary and appropriate; and (ii) will not present an undue risk of abuse, addiction or diversion.

If a third prescription is issued to a patient for an opioid, the practitioner is required to enter into a pain management agreement with the patient. Finally, any health care professional authorized to prescribe an opioid shall take part in at least one educational credit (in each reporting period) related to prescribing opioid drugs.

This law takes effect 90 days from enactment and the insurance provisions will be incorporated in any new or renewed insurance contracts following the effective date.