reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-6.10 - Eligibility for enrollment in medical service corporation

17:48A-6.10. Eligibility for enrollment in medical service corporation
2. Notwithstanding any other provision of law to the contrary, a medical service corporation shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a medical service corporation contract providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance.
L.1995,c.291,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-6.11 - Medical service corporation contract, exclusion, rates, terms based on genetic information prohibited.

17:48A-6.11 Medical service corporation contract, exclusion, rates, terms based on genetic information prohibited.
12. Every individual or group medical service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome.
L.1996,c.126,s.12.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7 - Formal requirements for subscription certificates

17:48A-7. Formal requirements for subscription certificates
In every such subscription certificate issued or delivered by any medical service corporation of this State:
(a) All printed portions shall be plainly printed in type of which the face is not smaller than ten point;
(b) There shall be a brief description of the subscription certificate on its first page, and on its filing back in type of which the face is not smaller than fourteen points;
(c) The exceptions and limitations of the contract shall appear with the same prominence in the certificate as the benefits to which they apply; and
(d) If the contract contains any provisions purporting to make any portion of the articles, constitution or by-laws or regulations of the corporation or plans a part of the contract, such portion shall be set forth in full in the subscription certificate.
L.1940, c. 74, p. 190, s. 7. Amended by L.1944, c. 102, p. 262, s. 5.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7b - Reconstructive breast surgery; benefits

17:48A-7b. Reconstructive breast surgery; benefits
1. Every subscription certificate and group and individual contract providing medical service benefits 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 benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any contract providing out-of-hospital x-ray or radiation therapy, benefits for out-of-hospital chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the out-of-hospital x-ray or radiation therapy benefit. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the contract.
L.1983,c.51,s.1; 1983, c.51, s.1; amended 1997, c.75, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7c - Medical service contracts

17:48A-7c. Medical service contracts
Every group and individual contract providing medical service benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this amendatory and supplementary act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The maternity benefits shall be provided to the same extent as the benefits are provided in the contract for any other covered illness. If a fixed amount is specified in the contract for surgery, the fixed amount for a pregnancy-related surgical procedure shall be commensurate with the fixed amount payable for a surgical procedure of comparable difficulty and severity.
L. 1985, c. 274, s. 2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7d - Medical service corporation insurance benefits for preexisting condition.

17:48A-7d Medical service corporation insurance benefits for preexisting condition.
1. a. Notwithstanding any other provision of law to the contrary, no group health insurance contract issued by a medical service corporation pursuant to the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.), shall contain any provision which denies benefits for a preexisting condition to any person becoming a member of that group. A medical service corporation shall not include a preexisting condition as a factor in calculating the premium.
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any group contract.
c. This section shall apply to every group contract or policy in which the corporation or insurer has the right to change the premium.
L.1989, c.63, s.1; amended 2019, c.353, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7e - Medical service corporation to pay benefits for treatment of Wilm's tumor

17:48A-7e. Medical service corporation to pay benefits for treatment of Wilm's tumor
Every group or individual medical service corporation contract providing hospital or medical expense benefits shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the contract.
L.1990,c.71,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7f - Medical service corporation contract, mammogram examination benefits.

17:48A-7f Medical service corporation contract, mammogram examination benefits.
2. a. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting:
(1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and
(2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the medical service corporation of the medical necessity of the additional screening and diagnostic testing.
b. These benefits shall be provided to the same extent as for any other sickness under the contract.
c. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.1991, c.279, s.2; amended 1999, c.341, s.2; 2004, c.86, s.2; 2013, c.196, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7g - Medical service corporation, benefits for "off-label" drugs required

17:48A-7g. Medical service corporation, benefits for "off-label" drugs required
3. a. Except as provided in P.L.1992, c.161 (C.17B:27A-2 et al.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no group or individual medical service corporation contract which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which it has been prescribed in one of the following established reference compendia:
(1) the American Medical Association Drug Evaluations;
(2) the American Hospital Formulary Service Drug Information;
(3) the United States Pharmacopoeia Drug Information;
or, it is recommended by a clinical study or review article in a major peer-reviewed professional journal.
b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the contract for drugs prescribed for a treatment approved by the Food and Drug Administration.
c. This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.
L.1993,c.321,s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7j - Benefits for certain cancer treatments

17:48A-7j. Benefits for certain cancer treatments
2. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a medical service corporation shall offer under every group or individual medical service corporation contract providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance, on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the contract.
The offer required pursuant to this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium. Nothing in this section shall be construed to limit a medical service corporation in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section.
L.1995,c.100,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7k - Coverage for birth and natal care; medical service corporation

17:48A-7k. Coverage for birth and natal care; medical service corporation
2. a. Every individual or group contract that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide coverage for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
b. Notwithstanding the provisions of subsection a. of this section, a medical service corporation contract that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child.
c. Every medical service corporation shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996.
L.1995,c.138,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7m - Medical service corporation contract, Pap smear benefits

17:48A-7m. Medical service corporation contract, Pap smear benefits
3. No medical service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons shall be 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, unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting a Pap smear. The benefits shall be provided to the same extent as for any other medical condition under the contract.
As used in this section, and notwithstanding the provisions of this section to the contrary, "Pap smear" means an initial Pap smear and any confirmatory test when medically necessary and as ordered by the covered person's physician and includes all laboratory costs associated with the initial Pap smear and any such confirmatory test.
This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.1995, c.415, s.3; amended 2001, c.227, s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7n - Medical service corporation contract, prostate cancer testing

17:48A-7n. Medical service corporation contract, prostate cancer testing
3. No medical service corporation contract providing hospital or medical expense benefits for groups with greater than 49 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific anitgen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors.
The benefits shall be provided to the same extent as for any other medical condition under the contract.
This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.1996,c.125,s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7o - Coverage for minimum inpatient care following mastectomy by individual, group medical service corporation

17:48A-7o. Coverage for minimum inpatient care following mastectomy by individual, group medical service corporation
2. a. Every individual or group medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The contract shall not require a health care provider to obtain authorization from the medical service corporation for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section.
The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the medical service corporation under the contract.
The benefits shall be provided to the same extent as for any other sickness under the contract.
The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section.
L.1997,c.149,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7p - Applicability of Health Care Quality Act

17:48A-7p Applicability of Health Care Quality Act
26. Notwithstanding the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the contract meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.1997,c.192,s.26.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7q - Coverage for treatment of inherited metabolic diseases by medical service corporation.

17:48A-7q Coverage for treatment of inherited metabolic diseases by medical service corporation.
2. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be 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, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician.
For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician.
The benefits shall be provided to the same extent as for any other medical condition under the contract.
The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.1997,c.338,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7r - Medical service corporation to cover certain audiology, speech-language pathology services.

17:48A-7r Medical service corporation to cover certain audiology, speech-language pathology services.
3. Notwithstanding any other provision of P.L.1940, c.74 (C.17:48A-1 et seq.), benefits shall not be denied to any eligible individual for eligible services, as determined under the terms of the contract or as otherwise required by law, when the services are determined by a physician to be medically necessary and are performed or rendered to that individual by a licensed audiologist or speech-language pathologist within the scope of practice. The practices of audiology and speech-language pathology shall be deemed to be within the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.) and duly licensed audiologists and speech-language pathologists shall have such privileges and benefits in the scope of their practice under that act as are afforded thereunder to licensed physicians and surgeons in the scope of their practice.
L.1997,c.419,s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7s - Coverage for treatment of domestic violence injuries by medical service corporation.

17:48A-7s Coverage for treatment of domestic violence injuries by medical service corporation.
2. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no group or individual medical service corporation contract providing hospital or medical expense benefits shall contain any provision which denies benefits for expenses incurred in the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to a subscriber or other person covered thereunder. Benefits shall be provided to the same extent as for any other treatment under the contract. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.1998,c.97,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7t - Coverage for certain dental procedures for the severely disabled or child age five or under by medical service corporation

17:48A-7t. Coverage for certain dental procedures for the severely disabled or child age five or under by medical service corporation
2. a. No group or individual medical service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 amendatory and supplementary act, unless the contract provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided.
b. A group or individual medical service corporation contract may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions.
c. This section shall apply to all group or individual medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.1999,c.49,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7v - Coverage for hemophilia services by medical services corporation

17:48A-7v. Coverage for hemophilia services by medical services corporation
8. Notwithstanding the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the contract meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.2000,c.121,s.8.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7x - Medical service corporation to provide coverage for colorectal cancer screening.

17:48A-7x Medical service corporation to provide coverage for colorectal cancer screening.
2. a. Every medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.
b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force.
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2001,c.295,s.2; amended 2023, c.8, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7y - Medical service corporation prescription drug plans to cover certain infant formulas.

17:48A-7y Medical service corporation prescription drug plans to cover certain infant formulas.
2. A medical service corporation which provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that 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 benefits under the contract for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula.
The benefits shall be provided to the same extent as for any other prescribed items under the contract.
This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2001,c.361,s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7z - Contract issued under C.17:48A-1 et seq. required to cover certain out-of-network services.

17:48A-7z Contract issued under C.17:48A-1 et seq. required to cover certain out-of-network services.
8. Notwithstanding the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the contract meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
L.2001,c.367,s.8.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7aa - Medical service corporation to offer coverage for domestic partner.

17:48A-7aa Medical service corporation to offer coverage for domestic partner.
48. A medical service corporation that provides hospital or medical expense benefits under a contract that 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 P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3).
This section shall apply to those contracts in which the medical service corporation has reserved the right to change the premium.
L.2003,c.246,s.48.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7cc - Medical service corporation to provide benefits for orthotic and prosthetic appliances.

17:48A-7cc Medical service corporation to provide benefits for orthotic and prosthetic appliances.
2. a. Every medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 benefits to any person covered thereunder for expenses incurred in obtaining an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician.
As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3) and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).
b. On and after the effective date of this act, a medical service corporation contract shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.
c. The benefits shall be provided to the same extent as for any other medical condition under the contract.
d. The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2007, c.345, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7dd - Medical service corporation to provide coverage for hearing aids for certain persons aged 15 or younger.

17:48A-7dd Medical service corporation to provide coverage for hearing aids for certain persons aged 15 or younger.
3. A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 medically necessary expenses incurred in the purchase of a hearing aid for a covered person 15 years of age or younger, as provided in this section.
A medical service corporation contract shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A medical service corporation may limit the benefit provided in this section to $1,000 per hearing aid for each hearing-impaired ear every 24 months. A covered person may choose a hearing aid that is priced higher than the benefit payable under this section and may pay the difference between the price of the hearing aid and the benefit payable under this section, without financial or contractual penalty to the provider of the hearing aid.
The benefits shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2008, c.126, s.3.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7ee - Individual, group medical service corporation to provide installment payments to obstetrical provider for maternity services.

17:48A-7ee Individual, group medical service corporation to provide installment payments to obstetrical provider for maternity services.
2. a. Every individual or group medical service corporation contract that provides benefits for maternity services, and that 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 for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy.
b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means:
(1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or
(2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife.
c. This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2009, c.113, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7gg - Medical service corporation to provide coverage for oral anticancer medications.

17:48A-7gg Medical service corporation to provide coverage for oral anticancer medications.
2. a. A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the contract provides for intravenously administered or injected anticancer medications.
b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications.
c. A medical service corporation contract shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the contract as of the effective date of this act.
d. This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2011, c.188, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7hh - Medical service corporation to provide coverage for sickle cell anemia.

17:48A-7hh Medical service corporation to provide coverage for sickle cell anemia.
2. Every medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the contract provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the contract shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia.
The benefits shall be provided to the same extent as for any other medical condition under the contract.
This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2011, c.210, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7ii - Medical service corporation to provide coverage for prescription eye drops.

17:48A-7ii Medical service corporation to provide coverage for prescription eye drops.
2. a. A medical service corporation which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract 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 incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that:
(1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and
(2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.
b. The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2013, c.50, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7jj - Medical service corporation contract, coverage for synchronization of prescribed medications.

17:48A-7jj Medical service corporation contract, coverage for synchronization of prescribed medications.
2. a. Every group or individual medical service corporation contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person:
(1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications;
(2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and
(3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed.
b. This section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form.
L.2015, c.206, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7mm - Medical service corporation contract to cover digital tomosynthesis of the breast.

17:48A-7mm Medical service corporation contract to cover digital tomosynthesis of the breast.
2. a. A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 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 incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age.
b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract shall be applied.
c. This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
L.2017, c.305, s.2.
2023 New Jersey Revised Statutes › Title 17 - Corporations and Institutions for Finance and Insurance › Section 17:48A-7nn - Medical service corporation to provide coverage for donated human breast milk.

17:48A-7nn Medical service corporation to provide coverage for donated human breast milk.
2. a. A medical service corporation contract that provides hospital or 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 incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that:
(1) the covered person is an infant under the age of six months;
(2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and
(3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or
(4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions:
(a) a body weight below healthy levels determined by the licensed medical practitioner;
(b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or
(c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health.
b. The provisions of this section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
c. Nothing in this section shall preclude the medical service corporation from performing utilization review, including periodic review of the medical necessity of a particular service.
d. The benefits shall be provided to the same extent as for any other prescribed items under the contract.
e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the medical service corporation shall not be required to provide coverage of expenses pursuant to this section.
L.2017, c.309, s.2.