reglab/statecodes huggingface dataset:
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.8 - Coverage for hemophilia services by small employer plan

17B:27A-19.8. Coverage for hemophilia services by small employer plan
5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or 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 policy or 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 policies or contracts in which the carrier has reserved the right to change the premium.
L.2000,c.121,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.9 - Small employer health benefits plan to provide coverage for colorectal cancer screening.

17B:27A-19.9 Small employer health benefits plan to provide coverage for colorectal cancer screening.
7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, shall provide benefits to any 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 health benefits plan.
d. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
L.2001,c.295,s.7; amended 2023, c.8, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.10 - Policy, contract issued under C.17B:27A-17 et seq. required to cover certain out-of-network services.

17B:27A-19.10 Policy, contract issued under C.17B:27A-17 et seq. required to cover certain out-of-network services.
5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or 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 policies or contracts in which the carrier has reserved the right to change the premium.
L.2001,c.367,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.11 - Carrier offering plans pursuant to C.17B:27A-17 et seq. may offer additional plan with certain limited benefits.

17B:27A-19.11 Carrier offering plans pursuant to C.17B:27A-17 et seq. may offer additional plan with certain limited benefits.
5. In addition to the standard health benefits plans offered by a carrier on the effective date of this act, a carrier that writes small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) may also offer one or more of the plans through the carrier's network of providers, with no reimbursement for any out-of-network benefits other than emergency care, urgent care, and continuity of care. A carrier's network of providers shall be subject to review and approval or disapproval by the Commissioner of Banking and Insurance, in consultation with the Commissioner of Health, pursuant to regulations promulgated by the Department of Banking and Insurance, including review and approval or disapproval before plans with benefits provided through a carrier's network of providers pursuant to this section may be offered by the carrier. Policies or contracts written on this basis shall be rated in a separate rating pool for the purposes of establishing a premium, but for the purpose of determining a carrier's losses, these policies or contracts shall be aggregated with the losses on the carrier's other business written pursuant to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.).
L.2001, c.368, s.5; amended 2008, c.38, s.22; 2012, c.17, s.59.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.12 - Small employer health benefits plan to offer coverage for domestic partner.

17B:27A-19.12 Small employer health benefits plan to offer coverage for domestic partner.
54. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State 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).
The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.
L.2003,c.246,s.54.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.13 - Small employer health benefits plan, mammogram examination benefits.

17B:27A-19.13 Small employer health benefits plan, mammogram examination benefits.
8. a. Every small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any 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 carrier of the medical necessity of the additional screening and diagnostic testing.
b. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.
c. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium.
L.2004, c.86, s.8; amended 2013, c.196, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.14 - High deductible health plan, small employer, deductible inapplicable, certain circumstances.

17B:27A-19.14 High deductible health plan, small employer, deductible inapplicable, certain circumstances.
16. Notwithstanding the provisions of subsection k. of section 3 of P.L.1992, c.162 (C.17B:27A-19) regarding deductibles for a high deductible health plan, a health benefits plan offered pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) 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 for 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 small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2005,c.248,s.16.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.17 - Small employer health benefits plans to provide benefits for orthotic and prosthetic appliances.

17B:27A-19.17 Small employer health benefits plans to provide benefits for orthotic and prosthetic appliances.
7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 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 small employer health benefits plan 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 health benefits plan.
d. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2007, c.345, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.18 - Small employer health benefits plan to provide coverage for hearing aids for certain persons aged 15 or younger.

17B:27A-19.18 Small employer health benefits plan to provide coverage for hearing aids for certain persons aged 15 or younger.
8. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), 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 health benefits plan 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 carrier 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 health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2008, c.126, s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.19 - Small employer health benefits plan to provide installment payments to obstetrical provider for maternity services.

17B:27A-19.19 Small employer health benefits plan to provide installment payments to obstetrical provider for maternity services.
7. a. Every small employer health benefits plan 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 small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2009, c.113, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.21 - Small employer health benefits plan to provide coverage for oral anticancer medications.

17B:27A-19.21 Small employer health benefits plan to provide coverage for oral anticancer medications.
7. a. A small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), 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 plan 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 small employer health benefits plan 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 plan as of the effective date of this act.
d. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2011, c.188, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.22 - Small employer health benefits plan to provide coverage for sickle cell anemia.

17B:27A-19.22 Small employer health benefits plan to provide coverage for sickle cell anemia.
8. Every small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State, 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 plan provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the plan 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 health benefits plan.
This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2011, c.210, s.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.23 - Small employer health benefits plan to provide coverage for prescription eye drops.

17B:27A-19.23 Small employer health benefits plan to provide coverage for prescription eye drops.
7. a. A small employer health benefits plan 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 small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2013, c.50, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.24 - Small employer health benefits plan, coverage for synchronization of prescribed medications.

17B:27A-19.24 Small employer health benefits plan, coverage for synchronization of prescribed medications.
8. a. Every small employer health benefits plan delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), 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 health benefits plans in which the carrier 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.8.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.24a - Carrier, small-employer health benefits plan, prescription drug formulary, flexibility, limitations.

17B:27A-19.24a Carrier, small-employer health benefits plan, prescription drug formulary, flexibility, limitations.
9. a. Except as provided in subsection b. of this section, a carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), may use a prescription drug formulary to limit or exclude coverage for prescription drugs, provided that the carrier offers at least one plan with an open formulary and the carrier demonstrates to the satisfaction of the board that utilization and medical review panels are in place to allow formulary flexibility as necessary in the best interest of the insured person.
b. A carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall not adopt a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition, and medically appropriate for a particular patient, are required to be administered in order to be covered by a health benefits plan.
c. Notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary, the department shall, as appropriate and no later than in time for plan year 2025, update rules and regulations to ensure consistency with the provisions of this section and P.L.2023, c.194 (C.17B:27A-33.1 et al.) immediately upon filing with the Office of Administrative Law. The rules and regulations adopted pursuant to this subsection shall be in effect only for plan year 2025. The rules and regulations shall thereafter be adopted, amended, or readopted for plan years 2026 and thereafter by the department in accordance with the requirements of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).
L.2023, c.194, s.9.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.24b - Carrier, prescription drug formulary, exceptions and appeals process.

17B:27A-19.24b Carrier, prescription drug formulary, exceptions and appeals process.
10. a. A carrier that uses a prescription drug formulary pursuant to section 9 of P.L.2023, c.194 (C.17B:27A-19.24a) shall establish a clinically sound and well-communicated exceptions and appeals process, or incorporate into the carrier's existing appeals process, the requirements of this section.
b. The process shall provide insureds with step-by-step directions to initiate the exceptions and appeals process and, for a prescription drug that is nonpreferred, not require an insured who obtains that prescription drug to pay an amount greater than the cost-sharing tier level associated with the preferred prescription drug if the prescriber determines that therapeutically similar drug is medically inappropriate.
c. A carrier shall show cause before denying payment for a prescription drug when a prescriber has deemed the carrier's recommended substitute medically inappropriate.
d. An insured may apply to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) to appeal a carrier decision, and the program shall render a decision as promptly as the patient's condition mandates.
e. The department shall collect information from each carrier subject to this section to conduct an annual evaluation of the exceptions and appeals processes established pursuant to this section with regard to the appropriateness of the burden of the process on consumers and clinicians and the effects on patient health outcomes.
L.2023, c.194, s.10.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.27 - Small employer health benefits plan to cover digital tomosynthesis of the breast.

17B:27A-19.27 Small employer health benefits plan to cover digital tomosynthesis of the breast.
7. a. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 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 health benefits plan shall be applied.
c. This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2017, c.305, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.28 - Small employer health benefits plan to provide coverage for donated human breast milk.

17B:27A-19.28 Small employer health benefits plan to provide coverage for donated human breast milk.
7. a. A small employer health benefits plan 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 small employer health benefits plans in which the carrier has reserved the right to change the premium.
c. Nothing in this section shall preclude the carrier 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 plan.
e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the carrier shall not be required to provide coverage of expenses pursuant to this section.
L.2017, c.309, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.30 - Small employer health benefits plan to meet essential health benefits requirements.

17B:27A-19.30 Small employer health benefits plan to meet essential health benefits requirements.
2. a. A small employer health benefits plan subject to P.L.1992, c.162 (C.17B:27A-17 et seq.) shall provide coverage under every plan delivered, issued, executed or renewed in this State, on or after the effective date of this act, that meets the essential health benefits requirements provided by this section.
b. Pursuant to section 3 of P.L.2019, c.354 (C.17B:27A-60), the commissioner shall define essential health benefits to include at least the following general categories and the items and services covered within the categories:
(1) ambulatory patient services;
(2) emergency services;
(3) hospitalization;
(4) maternity and newborn care;
(5) mental health and substance use disorder services, including behavioral health treatment;
(6) prescription drugs;
(7) rehabilitative and habilitative services and devices;
(8) laboratory services;
(9) preventive and wellness services and chronic disease management; and
(10) pediatric services, including oral and vision care.
c. A small employer health benefits plan shall provide for a level of coverage that is designed to provide benefits that are actuarially equivalent to:
(1) 60 percent of the full actuarial value of the benefits provided under the plan;
(2) 70 percent of the full actuarial value of the benefits provided under the plan; or
(3) 80 percent of the full actuarial value of the benefits provided under the plan.
d. The level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection b. of this section are provided to a standard population, and without regard to the actual population to which the plan may provide benefits.
e. The commissioner shall develop guidelines to provide for a de minimis variation in the actuarial calculations used in determining the level of coverage of a plan to account for differences in actuarial estimates.
L.2019, c.354, s.2.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.31 - Small employer health benefits plan to cover preventive services.

17B:27A-19.31 Small employer health benefits plan to cover preventive services.
7. a. An small employer health benefits plan 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 plan 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 plan 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 plan does not have in its network a provider who can provide an item or service described in subsection a. of this section, the plan 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 plan 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 plan 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. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
L.2019, c.360, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.32 - Small employer health benefits plan to provide certain coverage for prescription drugs.

17B:27A-19.32 Small employer health benefits plan to provide certain coverage for prescription drugs.
7. a. Notwithstanding any other provision of law to the contrary, a carrier that offers a small employer health benefits plan that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall ensure that at least 25 percent of all plans, or at least one plan if the carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the small employer market pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), shall conform with the following:
(1) (a) a health benefits plan 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) a health benefits plan 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) a health benefits plan 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 those health benefits plans in which the carrier has reserved the right to change the premium.
L.2019, c.471, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.33 - Small employer health benefits plan to cover adolescent depression screenings.

17B:27A-19.33 Small employer health benefits plan to cover adolescent depression screenings.
7. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), 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 benefits shall be provided to the same extent as for any other condition under the health benefits plan, except that the carrier 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 health benefits plans in which the carrier has reserved the right to change the premium.
L.2021, c.73, s.7.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.35 - Small employer health benefits plan, coverage, insulin for diabetes treatment.

17B:27A-19.35 Small employer health benefits plan, coverage, insulin for diabetes treatment.
22. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide coverage to an enrollee or other person covered thereunder for insulin for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35per 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.
The benefits shall be provided to the same extent as for any other condition under the health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2023, c.105, s.22.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.36 - Small employer health benefits plan, coverage, epinephrine auto-injector device.

17B:27A-19.36 Small employer health benefits plan, coverage, epinephrine auto-injector device.
23. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), 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 carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.
The benefits shall be provided to the same extent as for any other condition under the health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2023, c.105, s.23.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-19.37 - Small employer health benefits plan, coverage, prescription asthma inhaler.

17B:27A-19.37 Small employer health benefits plan, coverage, prescription asthma inhaler.
24. A small employer health benefits plan that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.), shall provide benefits to an enrollee or other person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 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 carrier from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section.
The benefits shall be provided to the same extent as for any other condition under the health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
L.2023, c.105, s.24.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-20 - Coinsurance, deductibles applicable

17B:27A-20. Coinsurance, deductibles applicable
4. Plans required to be offered under P.L.1992, c.162 (C.17B:27A-17 et seq.) may be subject to coinsurance and deductibles, which may vary by selected portions of the coverage. The department and the boards of directors of the New Jersey Individual Health Coverage Program and New Jersey Small Employer Health Benefits Program may promulgate regulations to create standard plans or plan design requirements. The standard plans or plan design requirements may include minimum cost-sharing standards, provided that the standards enable carriers to design and offer plans for the bronze, silver, gold, and platinum metal levels as defined under the actuarial value calculations pursuant to the federal "Patient Protection and Affordable Care Act," Pub.L.111-148, as amended by the "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152. In promulgating these regulations, the commissioner and boards of directors shall consider the best interests of consumers, the health of the markets, and plan design that promotes utilization of high value primary and preventative care to improve the health of the State's population. Any minimum standard regulations and standard plans promulgated by the commissioner or boards of directors pursuant to this section shall be reviewed and adjusted annually to achieve the goals of this section.
L.1992,c.162,s.4; amended 1993, c.162, s.3; 2023, c.194, s.4.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-20.1 - Rules, regulations.

17B:27A-20.1 Rules, regulations.
11. The department shall, no later than in time for plan year 2025 and immediately upon filing with the Office of Administrative Law, adopt rules and regulations, notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to the contrary, requiring no additional limitations on copayments, coinsurance, or deductibles for small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) beyond those set forth in the federal Patient Protection and Affordable Care Act, Pub.L.111-148, as amended by the federal "Health Care and Education Reconciliation Act of 2010," Pub.L.111-152 for plans issued pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.). The rules and regulations adopted pursuant to this section shall be in effect only for plan year 2025. Rules and regulations shall thereafter be adopted, amended, or readopted for plan years 2026 and thereafter by the department in accordance with the requirements of section 4 of P.L.1992, c.162 (C.17B:27A-20) and the requirements of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).
L.2023, c.194, s.11.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-21 - Standard coordination of benefits provisions applicable

17B:27A-21. Standard coordination of benefits provisions applicable
5. Coverage provided pursuant to this act shall be subject to standard coordination of benefits provisions for all persons covered under the policy or contract. Notwithstanding the provision of any other law to the contrary, the health benefits plan with the lowest actuarial value provided under this act shall not extend to any injury for which coverage is available or applicable pursuant to section 4 of P.L.1972, c.70 (C.39:6A-4), and that health benefits plan shall not be used as a substitute for any insurance required to be maintained pursuant to section 4 of P.L.1972, c.70 (C.39:6A-4).
L.1992,c.162,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-21.1 - Eligibility for enrollment in small employer health benefits plan

17B:27A-21.1 Eligibility for enrollment in small employer health benefits plan
5. Notwithstanding any other provision of law to the contrary, a carrier 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 small employer health benefits plan delivered, issued or executed in this State.
L.1995,c.291,s.5.
2023 New Jersey Revised Statutes › Title 17B - Insurance › Section 17B:27A-22 - Preexisting condition provisions.

17B:27A-22 Preexisting condition provisions.
6. a. No health benefits plan subject to this act shall include any provision excluding coverage for a preexisting condition regardless of the cause of the condition.
b. (Deleted by amendment, P.L.2019, c.353)
c. (Deleted by amendment, P.L.2019, c.353)
L.1992, c.162, s.6; amended 1995, c.298, s.2; 1997, c.146, s.9; 2017, c.361, s.10; 2019, c.353, s.5.