2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-60 - Essential health benefits defined.

17B:27A-60 Essential health benefits defined.
3. In defining the essential health benefits pursuant to P.L.2019, c.354 (C.17B:27A-7.26 et al.), the commissioner shall:
a. ensure that the essential health benefits shall be at least as comprehensive as the essential health benefits required of plans subject to the essential health benefits requirements of the Affordable Care Act as of January 1, 2019;
b. ensure that the essential health benefits reflect an appropriate balance among the categories described in P.L.2019, c.354 (C.17B:27A-7.26 et al.), so that benefits shall not be unduly weighted toward any category;
c. not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;
d. take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;
e. ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life;
f. provide that if a stand-alone dental plan is offered through the exchange, another health plan offered through the exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required; and
g. periodically review the essential health benefits under P.L.2019, c.354 (C.17B:27A-7.26 et al.), and provide a report to the Governor and the Legislature that provides:
(1) an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;
(2) an assessment of whether the essential health benefits need to be modified or updated to account for changes in medical evidence or scientific advancement;
(3) information on how the essential health benefits will be modified to address any gaps in access or changes in the evidence base; and
(4) an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in P.L.2019, c.354 (C.17B:27A-7.26 et al.);
h. periodically update the essential health benefits to address any gaps in access to coverage or changes in the evidence base the commissioner identifies in the review conducted pursuant to this section; and
i. establish limits on the dollar amounts of cost-sharing that may be imposed pursuant to a plan with respect to self-only coverage or coverage other than self-only coverage for a plan year. The limits initially established pursuant to this subsection shall not exceed the dollar amounts in effect under section 1302 of the Patient Protection and Affordable Care Act, Pub. L. 111-148 (42 U.S.C. s.18022), as those limits were in effect on June 1, 2020.
L.2019, c.354, s.3.