reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.13 - HMO certificate of authority, prostate cancer testing

26:2J-4.13. HMO certificate of authority, prostate cancer testing
5. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee which include an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen 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 health care services 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 for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
L.1996,c.125,s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.14 - HMO to provide benefits for reconstructive breast surgery.

26:2J-4.14 HMO to provide benefits for reconstructive breast surgery.
6. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.1997, c.75 unless the health maintenance organization provides health care services to any enrollee, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and prostheses and, under any contract for health care services providing outpatient x-ray or radiation therapy, outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy.
The health care services shall be provided to the same extent as for any other medical condition under the contract for health care services.
The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
L.1997, c.75, s.6; amended 2012, c.17, s.267.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.15 - Coverage for minimum inpatient care following mastectomy by HMO.

26:2J-4.15 Coverage for minimum inpatient care following mastectomy by HMO.
8. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 health care services 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 enrollee agreement shall not require a health care provider to obtain authorization from the health maintenance organization 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 health maintenance organization under the enrollee agreement.
The health care services shall be provided to the same extent as for any other sickness under the enrollee agreement.
The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
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.8; amended 2012, c.17, s.268.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.16 - Applicability of Health Care Quality Act

26:2J-4.16 Applicability of Health Care Quality Act
28. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act unless the health maintenance organization 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 enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.1997,c.192,s.28.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.17 - Coverage for treatment of inherited metabolic diseases by health maintenance organization.

26:2J-4.17 Coverage for treatment of inherited metabolic diseases by health maintenance organization.
8. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to each enrollee for 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 enrollee'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 health care services 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 for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
L.1997, c.338, s.8; amended 2012, c.17, s.269.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.18 - Coverage for treatment of domestic violence injuries by health maintenance organization.

26:2J-4.18 Coverage for treatment of domestic violence injuries by health maintenance organization.
6. 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 health maintenance organization shall deny health care services for 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 its enrollees. Services shall be provided to the same extent as for any other treatment. The provisions of this section shall apply to all certificates of authority in which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.1998,c.97,s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.19 - Coverage for certain dental procedures for the severely disabled or child age five or under by HMO.

26:2J-4.19 Coverage for certain dental procedures for the severely disabled or child age five or under by HMO.
6. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act unless the health maintenance organization provides health care services to an enrollee who is severely disabled or a child age five or under for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the enrollee agreement which requires hospitalization or general anesthesia for dental services rendered by a participating dentist regardless of where the dental services are provided.
b. A health maintenance organization 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 contracts for health care services in which the health maintenance organization has reserved the right to change the schedule of charges.
L.1999, c.49, s.6; amended 2012, c.17, s.270.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.21 - HMO to provide continuing nursing home care, certain.

26:2J-4.21 HMO to provide continuing nursing home care, certain.
1. a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization offers health care services in conformance with the provisions of subsection b. of this section.
b. If an enrollee is a resident of a skilled nursing facility, continuing care retirement community, or a retirement community which operates a skilled nursing facility on the premises of the community, regardless of whether the health maintenance organization is under contract with the skilled nursing facility or the skilled nursing facility at the continuing care retirement community or retirement community, the enrollee's primary care physician shall refer the enrollee to the skilled nursing facility or the community's Medicare-certified skilled nursing unit, as applicable, rather than to a skilled nursing facility separate from the facility or the community of origin, if:
(1) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility has the capacity to provide the services the enrollee needs;
(2) the primary care physician, in consultation with the enrollee or a representative of the enrollee's family, determines that the referral is in the best interest of the enrollee;
(3) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility agrees to be reimbursed at the same contract rate negotiated by the health maintenance organization with similar providers for the same services and supplies in the same geographic area; and
(4) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility meets all applicable State licensing and certification requirements.
c. For the purposes of this act, "continuing care retirement community" means a continuing care facility operating under a certificate of authority issued by the Department of Community Affairs pursuant to P.L.1986, c.103 (C.52:27D-330 et seq.), and "retirement community" means a retirement community which is registered with the Department of Community Affairs pursuant to P.L.1977, c.419 (C.45:22A-21 et seq.).
L.1999, c.332, s.1; amended 2012, c.17, s.272.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.22 - Coverage for hemophilia services by HMO

26:2J-4.22. Coverage for hemophilia services by HMO
10. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the health maintenance organization 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 enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2000,c.121,s.10.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.24 - HMO agreement to provide coverage for colorectal cancer screening.

26:2J-4.24 HMO agreement to provide coverage for colorectal cancer screening.
8. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 health care services to any enrollee 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 health care services shall be provided to the same extent as for any other medical condition under the enrollee agreement.
d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2001, c.295, s.8; amended 2012, c.17, s.273; 2023, c.8, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.25 - Health maintenance organization prescription drug plans to cover certain infant formulas.

26:2J-4.25 Health maintenance organization prescription drug plans to cover certain infant formulas.
6. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization that provides health care services for prescription drugs under a contract, unless the health maintenance organization also provides health care services 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 health care services shall be provided to the same extent as for any other prescribed items under the contract.
The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.2001,c.361,s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.26 - HMO required to cover certain out-of-network services.

26:2J-4.26 HMO required to cover certain out-of-network services.
10. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act unless the health maintenance organization 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 enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2001,c.367,s.10.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.27 - HMO to offer coverage for domestic partner.

26:2J-4.27 HMO to offer coverage for domestic partner.
52. Every health maintenance organization contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to an enrollee for an enrollee'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).
The provisions of this section shall apply to contracts in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2003,c.246,s.52.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.28 - HMO, high deductible, coverage for preventive care.

26:2J-4.28 HMO, high deductible, coverage for preventive care.
11. A certificate of authority to establish and operate a health maintenance organization, which organization offers a contract that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the health maintenance organization offers health care services to any enrollee which include services provided in-network which represent medically necessary preventive care as permitted by that federal law.
The services provided pursuant to this section shall be provided to the same extent as for any other medical condition under the contract, except that a deductible shall not be applied for services provided pursuant to this section. This section shall apply to all contracts under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.2005, c.248, s.11; amended 2012, c.17, s.274.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.29 - Health service corporation, coverage for prescription female contraceptives.

26:2J-4.29 Health service corporation, coverage for prescription female contraceptives.
12. Notwithstanding the provisions of section 4 of P.L.1995, c.316 (C.26:2J-4.10) regarding deductibles for a high deductible health plan, a contract offered by a health maintenance organization, which certificate of authority to establish and operate is issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not apply a deductible for any benefits in which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.).
This section shall apply to all contracts under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.2005, c.248, s.12; amended 2012, c.17, s.275.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.31 - HMOs to provide benefits for orthotic and prosthetic appliances.

26:2J-4.31 HMOs to provide benefits for orthotic and prosthetic appliances.
8. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services for 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 health maintenance organization 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 enrollee agreement.
d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2007, c.345, s.8; amended 2012, c.17, s.276.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.32 - Health maintenance organization to provide coverage for hearing aids for certain persons aged 15 or younger.

26:2J-4.32 Health maintenance organization to provide coverage for hearing aids for certain persons aged 15 or younger.
9. A health maintenance organization contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 health care services for medically necessary expenses incurred in the purchase of a hearing aid for an enrollee 15 years of age or younger, as provided in this section.
The health care services shall include the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A health maintenance organization may limit the health care services provided in this section to $1,000 per hearing aid for each hearing-impaired ear every 24 months. An enrollee may choose a hearing aid that is priced higher than the health care services payable under this section and may pay the difference between the price of the hearing aid and the health care services payable under this section, without financial or contractual penalty to the provider of the hearing aid.
The health care services shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved.
L.2008, c.126, s.9.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.33 - Health maintenance organization to provide installment payments to obstetrical provider for maternity services.

26:2J-4.33 Health maintenance organization to provide installment payments to obstetrical provider for maternity services.
8. a. Every certificate of authority to establish and operate a health maintenance organization issued or continued in this State pursuant to P.L.1973, c.337 (C.26:2J-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, for a health maintenance organization which provides benefits for maternity services, 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 enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
L.2009, c.113, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.35 - HMO to provide coverage for oral anticancer medications.

26:2J-4.35 HMO to provide coverage for oral anticancer medications.
8. a. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 health care services 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 covered 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 health maintenance organization 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 contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved.
L.2011, c.188, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.36 - HMO to provide coverage for sickle cell anemia.

26:2J-4.36 HMO to provide coverage for sickle cell anemia.
6. Every health maintenance organization contract that provides health care services and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 health care services to an enrollee for the medical treatment of sickle cell anemia and, if the contract provides health care services for outpatient prescription drugs, then the contract shall provide health care services to an enrollee for prescription drugs for the treatment of sickle cell anemia.
The health care services shall be provided to the same extent as for any other medical condition under the contract.
The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
L.2011, c.210, s.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.37 - Health maintenance organization to provide coverage for prescription eye drops.

26:2J-4.37 Health maintenance organization to provide coverage for prescription eye drops.
8. a. A health maintenance organization contract which provides hospital or medical expense benefits that include coverage for prescription eye drops, issued or continued 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 enrollee 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 those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges.
L.2013, c.50, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.38 - Health maintenance organization, coverage for synchronization of prescribed medications.

26:2J-4.38 Health maintenance organization, coverage for synchronization of prescribed medications.
6. a. Every certificate of authority to establish and operate a health maintenance organization in this State issued, continued or renewed in this State, or approved for issuance, continuation 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 enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.
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.6.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.41 - HMO to cover digital tomosynthesis of the breast.

26:2J-4.41 HMO to cover digital tomosynthesis of the breast.
8. a. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 contracts for health care services under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage.
L.2017, c.305, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.42 - HMO to provide coverage for donated human breast milk.

26:2J-4.42 HMO to provide coverage for donated human breast milk.
8. a. A health maintenance organization 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 contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges.
c. Nothing in this section shall preclude the health maintenance organization 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 health maintenance organization shall not be required to provide coverage of expenses pursuant to this section.
L.2017, c.309, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.43 - Health maintenance organization to provide coverage for standard fertility preservation services.

26:2J-4.43 Health maintenance organization to provide coverage for standard fertility preservation services.
5. a. A health maintenance organization contract that provides hospital or medical expense benefits for groups with more than 50 persons 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 standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility.
For the purposes of this section:
"Iatrogenic infertility" means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes.
"May directly or indirectly cause" means a medical treatment with a likely side effect of iatrogenic infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health.
"Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes.
The benefits shall be provided to the same extent as for any other medical condition under the contract. The same copayments, deductibles, and benefit limits shall apply to the provision of standard fertility preservation services pursuant to this section as those applied to other medical or surgical benefits under the contract.
b. A health maintenance organization providing coverage under this section shall not determine the provision of standard fertility preservation services based on an enrollee's expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life, or other health conditions, or based on personal characteristics, including age, sex, sexual orientation, marital status, or gender identity.
c. This section shall apply to those health maintenance organization contracts in which the health maintenance organization has reserved the right to change the premium.
L.2019, c.306, s.5.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.45 - Health maintenance organization to cover preventive services.

26:2J-4.45 Health maintenance organization to cover preventive services.
8. a. A health maintenance organization 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, without requiring any cost sharing, for the following preventive services:
(1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force;
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and
(4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.
b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall:
(a) require a contract which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or
(b) preclude a contract which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider.
(2) If a contract does not have in its network a provider who can provide an item or service described in subsection a. of this section, the contract shall cover the item or service when performed by an out-of-network provider, and shall not impose cost sharing with respect to that item or service.
c. (1) A contract shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued.
(2) (a) Except as provided in subparagraph (b) of this paragraph, a contract that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year.
(b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section.
d. The provisions of this section shall apply to those contracts in which the health maintenance organization has reserved the right to change the premium.
L.2019, c.360, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.46 - Health maintenance organization to provide certain coverage for prescription drugs.

26:2J-4.46 Health maintenance organization to provide certain coverage for prescription drugs.
8. a. Notwithstanding any other provision of law to the contrary, a health maintenance organization that offers a contract that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, shall ensure that at least 25 percent of all plans, or at least one plan if the organization offers less than four plans, offered by the organization in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), and in the small employer market pursuant to P.L.1992, c.162 (C.17B:27A-17), shall conform with the following:
(1) (a) an agreement that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug;
(b) an agreement that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug;
(c) an agreement that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph;
(2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and
(3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection.
b. The provisions of this section shall apply to all agreements in which the health maintenance organization has reserved the right to change the premium.
L.2019, c.471, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.47 - Health maintenance organization to cover adolescent depression screenings.

26:2J-4.47 Health maintenance organization to cover adolescent depression screenings.
8. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-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 screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service.
The health care services shall be provided to the same extent as for any other condition under the contract, except that the health maintenance organization shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance.
This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved.
L.2021, c.73, s.8.
2023 New Jersey Revised Statutes › Title 26 - Health and Vital Statistics › Section 26:2J-4.49 - Contract, health care services, coverage, epinephrine auto-injector device.

26:2J-4.49 Contract, health care services, coverage, epinephrine auto-injector device.
17. A contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law.
Nothing in this section shall prevent a health maintenance organization from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.
L.2023, c.105, s.17.