Groundbreaking Legislation Will Mandate Insurance Coverage, Limit Opioid Prescriptions, Boost Education & Awareness
An Assembly panel on Monday approved bipartisan legislation sponsored by Speaker Vincent Prieto and Assembly Democrats John McKeon, Shavonda Sumter and Joseph Lagana that employs a multi-faceted approach to tackle the continuing opioid crisis in New Jersey from every angle.
The legislation (A-3) employs a comprehensive strategy to address the opioid epidemic, including mandated insurance coverage for substance use disorders, restrictions on the prescription of opioids, patient notification on the dangers of abuse of controlled dangerous substances, and professional education on topics related to prescription opioids.
“While this legislation aims to prevent addiction to begin with, it also recognizes the realities that have taken hold, and substantially bolsters treatment options and health benefits for those that have succumbed to this epidemic,” said Prieto (D-Bergen/Hudson). “We are committed to working together with our colleagues on both sides of the aisle, in both houses and in all branches of government because this is an issue that has touched the lives of nearly every New Jerseyan either directly or indirectly.”
“This bill is comprehensive in nature in that it addresses addiction in the here and now and also implements practical controls to help prevent future addictions,” said McKeon (D-Essex/Morris). “Improving access to treatment, limiting prescriptions and boosting education and awareness are all important steps towards stemming this crisis and getting people on the road to recovery.”
“We’ve heard firsthand from patients, family members and advocates about the nightmares of trying to gain access to treatment,” said Sumter (D-Bergen/Passaic). “What’s become crystal clear is that we need to make sure the system is working for patients and not against them. Treatment should be readily accessible and affordable when someone finally makes that all important decision to tackle their addiction.”
“Opioid addiction needs to be treated for what it is – a medical crisis,” said Lagana (D-Bergen/Passaic). “There are few public health issues more pressing than this right now and we need to tackle it in a way that will help breakdown the stigmas associated with it and get people the real, substantive treatment they need in a timely and affordable manner.”
HEALTH INSURANCE COVERAGE
Specifically, the bill requires health insurance carriers, the State Health Benefits Program, and the School Employees’ Health Benefits Program to provide unlimited benefits for inpatient and outpatient treatment of substance use disorders at in-network facilities, which 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.
The bill stipulates 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.
Furthermore, providers of treatment for substance use disorders to persons covered under an 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 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.
Likewise, 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 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 bill also makes clear that the provisions requiring health insurance coverage do not apply to plans administered by the Department of Human Services, such as Medicare and Medicaid, which are regulated by the federal government.
The bill also places certain restrictions on how opioids and other Schedule II pain medicines may be prescribed. In cases of acute pain, the bill provides that a practitioner shall not issue an initial prescription for an opioid drug in a quantity exceeding a five-day supply.
Additionally, in cases of acute pain, prior to issuing an initial prescription of a course of treatment that includes a Schedule II pain medicine or any other opioid drug, a practitioner shall:
1) take and document the results of a thorough medical history, including the patient’s experience with non-opioid medication and non-pharmacological pain management approaches and substance abuse history;
2) conduct a physical examination, as appropriate, and document the results;
3) develop a treatment plan, with particular attention focused on determining the cause of the patient’s pain;
4) access relevant prescription monitoring information under the Prescription Monitoring Program; and
5) limit the supply of any opioid drug prescribed for acute pain to a duration of no more than five days as determined by the directed dosage and frequency of dosage.
No less than four days after issuing the initial prescription, the practitioner, after consultation with the patient, may issue a subsequent prescription for the drug to the patient in any quantity that complies with applicable state and federal laws, provided that:
1) the subsequent prescription would not be deemed an initial prescription under this section;
2) the practitioner determines the prescription is necessary and appropriate to the patient’s treatment needs and documents the rationale for the issuance of the subsequent prescription; and
3) the practitioner determines that issuance of the subsequent prescription does not present an undue risk of abuse, addiction, or diversion and documents that determination.
The bill also incorporates a notification component by requiring a practitioner to discuss the risks associated with the drugs being prescribed with the patient, or the patient’s parent or guardian, prior to issuing the initial prescription of a course of treatment that includes a Schedule II controlled dangerous substance or any other opioid drug, and again prior to issuing the third prescription of the course of treatment. The practitioner shall make a notation in the patient’s medical record acknowledging the discussion.
Additionally, at the time of the issuance of the third prescription for a prescribed opioid drug, the practitioner shall enter into a pain management agreement with the patient. When a Schedule II controlled dangerous substance or any other prescription opioid drug is continuously prescribed for three months or more for chronic pain, the practitioner shall:
1) review, at a minimum of every three months, the course of treatment, any new information about the etiology of the pain, and the patient’s progress toward treatment objectives and document the results of that review;
2) assess the patient prior to every renewal to determine whether the patient is experiencing problems associated with physical and psychological dependence and document the results of that assessment;
3) periodically make reasonable efforts, unless clinically contraindicated, to either stop the use of the controlled substance, decrease the dosage, try other drugs or treatment modalities in an effort to reduce the potential for abuse or the development of physical or psychological dependence and document with specificity the efforts undertaken;
4) review the Prescription Drug Monitoring information in accordance with current statute; and
5) monitor compliance with the pain management agreement and any recommendations that the patient seek a referral.
The bill exempts the following from the prescription limitations listed above: a patient who is currently in active treatment for cancer, receiving hospice care from a licensed hospice or palliative care, or is a resident of a long term care facility, and any medications that are being prescribed for use in the treatment of substance abuse or opioid dependence.
The bill also would require certain training on topics related to prescription opioid drugs for health care professionals who have the authority to prescribe opioid medications, including physicians, physician assistants, dentists, and optometrists, and advance practice nurses, who also have prescribing authority.
Health care professionals who do not have prescribing authority but who frequently interact with patients who may be prescribed opioids, as well as certified nurse midwives, would also be required to complete one continuing education credit on topics that topics related to prescription opioid drugs.
The bill also requires the Commissioner of Health, in consultation with the Commissioner of Banking and Insurance, to submit reports to the Legislature and the Governor concerning implementation of the bill six months and 12 months after the date of the bill’s enactment.
The bill was approved by the Assembly Financial Institutions and Insurance Committee.