An Act concerning insurance and Medicaid coverage for preventive care for developmental and behavioral needs in children and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
C.26:2S-41 Coverage for screening, prevention, treatment services of behavioral health issues in children.
1. a. A carrier that offers a health benefits plan in this State shall provide benefits to any subscriber for medical expenses incurred in screening, prevention, and treatment services of behavioral health issues in children. A carrier shall accept and reimburse claims for screening, prevention, and treatment using an at-risk diagnosis.
b. The benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract.
c. As used in this section:
“At-risk diagnosis” means a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and, instead, promotes preventive care. Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis, for children who are 18 years of age or younger.
"Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.
“Screening, prevention, and treatment” includes the prevention and early identification of mental health conditions without a behavioral health diagnosis. Services may include, but are not limited to, screenings and individual, group, and family psychotherapy to individuals with potential mental health disorders not yet diagnosed.
C.52:14-17.29qq Contracts purchased by the State Health Benefits Commission, behavioral health, children.
2. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall provide benefits to any covered person for medical expenses incurred in the screening, prevention, and treatment services of behavioral health issues in children. The contract shall allow for acceptance and reimbursement of claims for screening, prevention, and treatment using an at-risk diagnosis.
b. The benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract.
c. As used in this section:
“At-risk diagnosis” means a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and, instead, promotes preventive care. Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis, for children who are 18 years of age or younger.
“Screening, prevention, and treatment” includes the prevention and early identification of mental health conditions without a behavioral health diagnosis. Services may include, but are not limited to, screenings and individual, group, and family psychotherapy to individuals with potential mental health disorders not yet diagnosed.
C.52:14-17.46.6y Contracts purchased by the School Employees' Health Benefits Commission, behavioral health, children.
3. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall provide benefits to any covered person for medical expenses incurred in the screening, prevention, and treatment services of behavioral health issues in children. The contract shall allow for acceptance and reimbursement of claims for screening, prevention, and treatment using an at-risk diagnosis.
b. The benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract.
c. As used in this section:
“At-risk diagnosis” means a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and, instead, promotes preventive care. Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis, for children who are 18 years of age or younger.
“Screening, prevention, and treatment” includes the prevention and early identification of mental health conditions without a behavioral health diagnosis. Services may include, but are not limited to, screenings and individual, group, and family psychotherapy to individuals with potential mental health disorders not yet diagnosed.
C.30:4D-6bb Contracts purchased by the Division of Medical Assistance and Health Services, managed care organization, behavioral health, children.
4. a. Notwithstanding any law, rule, or regulation to the contrary, the Division of Medical Assistance and Health Services within the Department of Human Services, or a managed care organization that contracts with the division to provide medical services to beneficiaries of the NJ FamilyCare program, shall ensure the provision of benefits for medical expenses incurred in screening, prevention, and treatment services of behavioral health issues in children. The division or the managed care organization shall accept and reimburse claims for screening, prevention, and treatment using an at-risk diagnosis.
b. The department may take any administrative action necessary to effectuate the provisions of this section, including modifying or amending any applicable contract and promulgating, amending, or repealing any guidance, guidelines, or rules, which rules or amendments thereto shall be effective immediately upon filing with the Office of Administrative Law for a period not to exceed 12 months, and may, thereafter, be amended, adopted, or readopted in accordance with the provisions of the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.).
c. The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this section and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.
d. As used in this section:
“At-risk diagnosis” means a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and, instead, promotes preventive care. Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis, for children who are 18 years of age or younger.
“Screening, prevention, and treatment” includes the prevention and early identification of mental health conditions without a behavioral health diagnosis. Services may include, but are not limited to, screenings and individual, group, and family psychotherapy to individuals with potential mental health disorders not yet diagnosed.
5. This act shall take effect on the 90th day next following enactment and shall apply to policies, plans, and contracts delivered, executed, issued, or renewed on or after that date.
Approved January 20, 2026.