N.J.S.A. 17:48-6

Contracts; certificates; contents.

17:48-6 Contracts; certificates; contents. 6. Every individual contract made by a corporation subject to the provisions of this chapter to furnish services to a subscriber shall provide for the furnishing of services for a period of 12 months, and no contract shall be made providing for the inception of such services at a date later than one year after the actual date of the making of such contract. Any such contract may provide that it shall be automatically renewed from year to year unless there shall have been at least 30 days' prior written notice of termination by either the subscriber or the corporation. In the absence of fraud or material misrepresentation in the application for a contract or for reinstatement, no contract with an individual subscriber shall be terminated by the corporation unless all contracts of the same type, in the same group, or covering the same classification of persons are terminated under the same conditions. No contract between any such corporation and a subscriber shall entitle more than one person to services, except that a contract issued as a family contract may provide that services will be furnished to a husband and wife; husband, wife, and their dependent child or children; or the subscriber and his (or her) dependent child or children. Adult dependent(s) of a subscriber may also be included for coverage under the contract of such subscriber. Whenever, pursuant to the provisions of a subscription certificate or group contract issued by a corporation, the former spouse of a named subscriber under such a certificate or contract is no longer entitled to coverage as an eligible dependent by reason of divorce, separate coverage for such former spouse shall be made available by the corporation on an individual non-group basis under the following conditions: (a) Application for such non-group coverage shall be made to the corporation by or on behalf of such former spouse no later than 31 days following the date his or her coverage under the prior certificate or contract terminated. (b) No new evidence of insurability shall be required in connection with the application for such non-group coverage, but any health exception, limitation, or exclusion applicable to said former spouse under the prior coverage may, at the option of the corporation, be carried over to the new non-group coverage. (c) The effective date of the new coverage shall be the day following the date on which such former spouse's coverage under the prior certificate or contract terminated. (d) The benefits provided under the non-group coverage issued to such former spouse shall be at least equal to the basic benefits provided in contracts then being issued by the corporation to new non-group applicants of the same age and family status. Family type contracts shall provide that the services applicable for children shall be payable with respect to a newly born child of the subscriber or his or her spouse from the moment of birth. The services for newly born children shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and abnormalities. If a subscription payment is required to provide services for a child, the contract may require that notification of birth of a newly born child and the required payment must be furnished to the service corporation within 90 days after the date of birth in order to have the coverage continue beyond such 90-day period. Nonfamily type contracts which provide for services to the subscriber, but not to family members or dependents of that subscriber, shall also provide services to newly born children of the subscriber which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and abnormalities, provided that application therefor and payment of the required subscription amount are made to include in said contract the coverage described in the preceding paragraph of this section within 90 days from the date of birth of a newborn child. A contract under which coverage of a dependent of a subscriber terminates at a specified age shall, with respect to an unmarried child, covered by the contract prior to attainment of age 19, who is incapable of self-sustaining employment by reason of an intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon such subscriber for support and maintenance, not so terminate while the contract remains in force and the dependent remains in such condition, if the subscriber has within 31 days of such dependent's attainment of the termination age submitted proof of such dependent's incapacity as described herein. The foregoing provisions of this paragraph shall not apply retrospectively or prospectively to require a hospital service corporation to insure as a covered dependent any child with an intellectual disability or physically handicapped child of the applicant where the contract is underwritten on evidence of insurability based on health factors required to be set forth in the application. In such cases, any contract heretofore or hereafter issued may specifically exclude such child with an intellectual disability or physically handicapped child from coverage. Every individual contract entered into by any such corporation with any subscriber thereto shall be in writing and a certificate stating the terms and conditions thereof shall be furnished to the subscriber to be kept by him. No such certificate form shall be made, issued, or delivered in this State unless it contains the following provisions: (a) A statement of the contract rate, or amount payable to the corporation by or on behalf of the subscriber for the original quarter-annual period of coverage and of the time or times at which, and the manner in which, such amount is to be paid, and a provision requiring 30 days' written notice to the subscriber before any change in the contract, including a change in the amount of subscription rate, shall take effect; (b) A statement of the nature of the services to be furnished and the period during which they will be furnished; and if there are any services to be excepted, a detailed statement of such exceptions printed as hereinafter specified; (c) A statement of the terms and conditions, if any, upon which the contract may be amended on approval of the commissioner or canceled or otherwise terminated at the option of either party. Any notice to the subscriber shall be effective if sent by mail to the subscriber's address as shown at the time on the plan's record, except that, in the case of persons for whom payment of the contract is made through a remitting agent, any such notice to the subscriber shall also be effective if a personalized notice is sent to the remitting agent for delivery to the subscriber, in which case it shall be the responsibility of the remitting agent to make such delivery. The notice to the subscriber as herein required shall be sent at least 30 days before the amendment, cancellation or termination of the contract takes effect. Any rider or endorsement accompanying such notice, and amending the rates or other provisions of the contract, shall be deemed to be a part of the contract as of the effective date of such rider or endorsement; (d) A statement that the contract includes the endorsements thereon and attached papers, if any, and contains the entire contract for services; (e) A statement that no statement by the subscriber in his application for a contract shall void the contract or be used in any legal proceeding thereunder, unless such application or an exact copy thereof is included in or attached to such contract, and that no agent or representative of such corporation, other than an officer or officers designated therein, is authorized to change the contract or waive any of its provisions; (f) A statement that if the subscriber defaults in making any payment under the contract, the subsequent acceptance of a payment by the corporation or by one of its duly authorized agents shall reinstate the contract, but with respect to sickness and injury may cover such sickness as may be first manifested more than 10 days after the date of such acceptance; (g) A statement of the period of grace which will be allowed the subscriber for making any payment due under the contract. Such period shall be not less than 10 days. In every such contract made, issued or delivered in this State: (a) All printed portions shall be plainly printed in type of which the face is not smaller than 10 point; (b) There shall be a brief description of the contract on its first page and on its filing back in type of which the face is not smaller than 14 point; (c) The exceptions of the contract shall appear with the same prominence as the benefits to which they apply; and (d) If the contract contains any provision purporting to make any portion of the articles, constitution or bylaws of the corporation a part of the contract, such portion shall be set forth in full. L.1938, c.366, s.6; amended 1956, c.142; 1964, c.104, s.1; 1966, c.236, ss.1,3; 1970, c.110; 1975, c.109, s.1; 1980, c.113, s.3; 2010, c.50, s.3; 2017, c.361, s.1; 2025, c.194, s.1. 17:48-6b. Benefits for reconstructive breast surgery 1. Every subscription certificate and group and individual contract providing hospital service benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the cost of prostheses and, under any contract providing outpatient x-ray or radiation therapy, benefits for 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 benefit. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the contract. L.1983,c.50,s.1; amended 1997, c.75, s.1. 17:48-6c. Hospital service contracts Every group and individual contract providing hospital service benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The maternity benefits shall be provided to the same extent as the hospitalization benefit is provided in the contract for any other covered illness. L. 1985, c. 276, s. 1. 17:48-6d. Benefits for blood products, blood infusion equipment Every group or individual contract providing hospital expense benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with hemophilia shall provide benefits for expenses incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia when the home treatment program is under the supervision of a State approved hemophilia treatment center. The benefits shall be provided to the same extent as for any sickness under the contract. As used in this act, "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles. Participation in a home treatment program shall not preclude further or additional treatment or care at any eligible facility if the number of home treatments, in accordance with a ratio of home treatments to benefit days established by regulation by the Commissioner of Insurance, does not exceed the total number of benefit days provided for any other sickness under the contract. L. 1987, c. 62, s. 1. 17:48-6e Hospital service corporation insurance benefits for preexisting condition. 2. a. Notwithstanding any other provision of law to the contrary, no group health insurance contract issued by a hospital service corporation pursuant to the provisions of P.L.1938, c.366 (C.17:48-1 et seq.), shall contain any provision which denies benefits for a preexisting condition to any person becoming a member of that group. A hospital service corporation shall not include a preexisting condition as a factor in calculating the premium. b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any group contract. c. This section shall apply to every group contract or policy in which the corporation or insurer has the right to change the premium. L.1989, c.63, s.2; amended 2019, c.353, s.1. 17:48-6f. Hospital service corporation to pay benefits for treatment of Wilm's tumor Every group or individual hospital service corporation contract providing hospital or medical expense benefits shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the contract. L.1990,c.71,s.1. 17:48-6g Hospital service corporation contract, mammogram examination benefits. 1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in conducting: (1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and (2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the hospital service corporation of the medical necessity of the additional screening and diagnostic testing. b. These benefits shall be provided to the same extent as for any other sickness under the contract. c. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.1991, c.279, s.1; amended 1999, c.341, s.1; 2004, c.86, s.1; 2013, c.196, s.1. 17:48-6h. Hospital service corporation, benefits for "off-label" drugs required 2. a. Except as provided in P.L.1992, c.161 (C.17B:27A-2 et al.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no group or individual hospital service corporation contract which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which it has been prescribed in one of the following established reference compendia: (1) the American Medical Association Drug Evaluations; (2) the American Hospital Formulary Service Drug Information; (3) the United States Pharmacopoeia Drug Information; or, it is recommended by a clinical study or review article in a major peer-reviewed professional journal. b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the contract for drugs prescribed for a treatment approved by the Food and Drug Administration. c. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug. L.1993,c.321,s.2. 17:48-6i. Hospital service corporation, benefits of health promotion 3. a. Every hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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.1999, c.339, shall provide benefits to any subscriber or other person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services: (1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin; blood pressure; blood glucose level; and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level; (2) For all persons 35 years of age or older, a glaucoma eye test every five years; (3) For all persons 40 years of age or older, an annual stool examination for presence of blood; (4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years; (5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 2 of P.L.1995, c.415 (C.17:48-6o); (6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 1 of P.L.1991, c.279 (C.17:48-6g); (7) For all adults, recommended immunizations; and (8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles. Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the hospital service corporation shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section. b. Every individual or group health care contract offered for sale in this State by a hospital service corporation pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no hospital service corporation shall be required to provide payment for benefits for a left-sided colon examination in excess of $150. c. The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made. d. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.). L.1993, c.327, s.3; amended 1999, c.339, s.1. 17:48-6j Requirements for hospital service corporation providing benefits for pharmacy services. 1. a. Notwithstanding any other provision of law to the contrary, no group or individual hospital service corporation contract which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, unless the contract: (1) Permits the subscriber, at the time of issuance, amendment or renewal, to select benefit coverage allowing the subscriber to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et seq.; (2) Provides that no pharmacy or pharmacist shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the contract provides for coverage by contracted or preferred providers for pharmaceutical services, provided the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the contract; (3) Provides that no copayment, fee, or other condition shall be imposed upon a subscriber selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all subscribers selecting a participating or contracting pharmacist or pharmacy; (4) (a) Provides that no subscriber shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy; (b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and (c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days; (5) Sets forth the auditing procedures to be used by the hospital service corporation and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor. No audit by a hospital service corporation shall include a review of any document relating to any person or prescription plan other than those reimbursable by the hospital service corporation; (6) Provides that the hospital service corporation, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the subscriber for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law; (7) The provisions of P.L.1999, c.395 shall apply to all contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395. b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any contract. c. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the subscriber charge. L.1993,c.378,s.1; amended 1999, c.395, s.1. 17:48-6k Benefits for certain cancer treatments 1. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a hospital service corporation shall offer under every group or individual hospital service corporation contract providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance, on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the contract. The offer required pursuant to this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. Nothing in this section shall be construed to limit a hospital service corporation in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section. L.1995,c.100,s.1. 17:48-6l. Coverage for birth and natal care; hospital service corporation 1. a. Every individual or group contract that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide coverage for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. b. Notwithstanding the provisions of subsection a. of this section, a hospital service corporation contract that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. c. Every hospital service corporation shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996. L.1995,c.138,s.1. 17:48-6m Hospital service corporation contracts, child screening, blood lead, hearing loss; immunizations. 2. No hospital service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in the following: a. Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children. b. All childhood immunizations as recommended by the Advisory Committee on Immunization Practices of the United States Public Health Service and the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1). A hospital service corporation shall notify its subscribers, in writing, of any change in coverage with respect to childhood immunizations and any related changes in premium. Such notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance. c. Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility. The benefits 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 benefits provided pursuant to this section; however, with respect to 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), a deductible shall not be applied for any benefits provided pursuant to this section which represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 6 of P.L.2005, c.248 (C.17:48-6dd). This section shall apply to all hospital service corporation contracts in which the health service corporation has reserved the right to change the premium. L.1995, c.316, s.2; amended 2001, c.373, s.11; 2005, c.248, s.4; 2012, c.17, s.35. 17:48-6n. Coverage, diabetes treatment, individual, group hospital service corporation. 1. a. Every individual or group hospital service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits to any subscriber or other person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. 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 $35 per 30-day supply. The provisions of this subsection 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 subsection 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 subsection 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. b. Each individual or group hospital service corporation contract shall also provide benefits for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of their diabetic condition, including information on proper diet. Benefits provided for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the subscriber's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Diabetes self-management education shall be provided by a dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or a registered pharmacist in the State qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the State of New Jersey. c. The benefits required by this section shall be provided to the same extent as for any other sickness under the contract. d. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.). f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional diabetes equipment and related supplies that are medically necessary for the treatment of diabetes and for which benefits shall be provided according to the provisions of this section. L.1995, c.331, s.1.; amended 2023, c.105, s.1. 17:48-6o. Hospital service corporation contract, Pap smear benefits 2. No hospital service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting a Pap smear. The benefits shall be provided to the same extent as for any other medical condition under the contract. As used in this section, and notwithstanding the provisions of this section to the contrary, "Pap smear" means an initial Pap smear and any confirmatory test when medically necessary and as ordered by the covered person's physician and includes all laboratory costs associated with the initial Pap smear and any such confirmatory test. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.1995, c.415, s.2; amended 2001, c.227, s.2. 17:48-6p. Hospital service corporation contract, prostate cancer testing 2. No hospital service corporation contract providing hospital or medical expense benefits for groups with greater than 49 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific 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 benefits shall be provided to the same extent as for any other medical condition under the contract. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.1996,c.125,s.2. 17:48-6q. Coverage for minimum inpatient care following mastectomy by individual, group hospital service corporation 1. a. Every individual or group hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide coverage for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The contract shall not require a health care provider to obtain authorization from the hospital service corporation for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section. The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the hospital service corporation under the contract. The benefits shall be provided to the same extent as for any other sickness under the contract. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section. L.1997,c.149,s.1. 17:48-6r Applicability of Health Care Quality Act 25. Notwithstanding the provisions of P.L.1938, c.366 (C.17:48-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the contract meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.1997,c.192,s.25. 17:48-6s Coverage for treatment of inherited metabolic diseases by hospital service corporation. 1. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the contract provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician. For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician. The benefits shall be provided to the same extent as for any other medical condition under the contract. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.1997,c.338,s.1. 17:48-6t Coverage for treatment of domestic violence injuries by hospital service corporation. 1. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no group or individual hospital service corporation contract providing hospital or medical expense benefits shall contain any provision which denies benefits for expenses incurred in the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to a subscriber or other person covered thereunder. Benefits shall be provided to the same extent as for any other treatment under the contract. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.1998,c.97,s.1. 17:48-6u. Coverage for certain dental procedures for the severely disabled or child age five or under by hospital service corporation 1. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act, unless the contract provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided. b. A group or individual hospital service corporation contract may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions. c. This section shall apply to all group or individual hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.1999,c.49,s.1. 17:48-6v Hospital service corporation to provide coverage for mental health conditions, substance use disorders; collaborative care model. 1. a. (1) Every individual and group hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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 mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the contract and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3). Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model. (2) As used in this section: "Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders. "Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented: (a) 99492 - Initial psychiatric collaborative care management; (b) 99493 - Subsequent psychiatric collaborative care management; and (c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time. "Same terms and conditions" means that the hospital service corporation cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits. "Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders. b. (Deleted by amendment, P.L.2019, c.58) c. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. d. Nothing in this section shall reduce the requirement for a hospital service corporation to provide benefits pursuant to section 1 of P.L.2017, c.28 (C.17:48-6nn). L.1999, c.106, s.1; amended 2019, c.58, s.1; 2022, c.33, s.1. 17:48-6w. Coverage for hemophilia services by hospital service corporations 7. Notwithstanding the provisions of P.L.1938, c.366 (C.17:48-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the contract meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.2000,c.121,s.7. 17:48-6x Hospital service corporation to provide coverage for treatment of infertility. 1. a. A hospital service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The hospital service corporation contract shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The hospital service corporation may provide that coverage for in vitro fertilization shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age. As used in this section: "Infertility" means a disease, condition, or status characterized by any of the following: (1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors; (2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or (3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older. Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation. "Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed. b. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3). c. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. d. The provisions of this section shall not apply to a hospital service corporation contract which, pursuant to a contract between the hospital service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services. e. Nothing in this section shall preclude the hospital service corporation from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines. L.2001, c.236, s.1; amended 2017, c.48, s.1; 2023, c.258, s.1. 17:48-6y Hospital service corporation to provide coverage for colorectal cancer screening. 1. a. Every hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any named subscriber or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person. b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force. c. The benefits shall be provided to the same extent as for any other medical condition under the contract. d. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2001,c.295,s.1; amended 2023, c.8, s.1. 17:48-6z Hospital service corporation prescription drug plans to cover certain infant formulas. 1. A hospital service corporation which provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits under the contract for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula. The benefits shall be provided to the same extent as for any other prescribed items under the contract. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2001,c.361,s.1. 17:48-6aa Contracts issued under C.17:48-1 et seq. required to cover certain out-of-network services. 7. Notwithstanding the provisions of P.L.1938, c.366 (C.17:48-1 et seq.) to the contrary, no individual or group contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the contract meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.2001,c.367,s.7. 17:48-6bb Hospital service corporation to offer coverage for domestic partner. 47. A hospital service corporation that provides hospital or medical expense benefits under a contract that is delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3). This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium. L.2003,c.246,s.47. 17:48-6cc Hospital service corporation, high deductible, coverage for preventive care. 5. No hospital service corporation contract providing hospital or medical expense benefits for groups with greater than 50 persons, 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 be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the contract provides benefits to any named subscriber or other person covered thereunder for expenses incurred in connection with any medically necessary benefits provided in-network that represent preventive care as permitted by that federal law. The benefits 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 benefits provided pursuant to this section. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2005,c.248,s.5. 17:48-6dd Hospital service corporation, high deductible, deductible inapplicable, certain circumstances. 6. Notwithstanding the provisions of section 2 of P.L.1995, c.316 (C.17:48-6m) regarding deductibles for a high deductible health plan, a contract offered by a hospital service corporation providing hospital or medical expense benefits for groups with greater than 50 persons, 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), 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 P.L.2005, c.248 (C.17:48E-35.27 et al.), 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 hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2005,c.248,s.6. 17:48-6ee Hospital service corporation, coverage for contraceptives. 1. a. A hospital service corporation that provides hospital or medical expense benefits shall provide coverage under every 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, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis: (1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions: (a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product. (b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. (c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration. (2) Voluntary male and female sterilization. (3) Patient education and counseling on contraception. (4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to: (a) Management of side effects; (b) Counseling for continued adherence to a prescribed regimen; (c) Device insertion and removal; (d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and (e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section. b. The coverage provided shall include prescriptions for dispensing contraceptives for: (1) (Deleted by amendment, P.L.2021, c.376) (2) up to a 12-month period at one time. c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed. (2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). d. This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium. e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13. L.2005, c.251, s.1; amended 2017, c.241, s.1; 2019, c.361, s.1; 2021, c.376, s.1. 17:48-6ff Hospital service corporation to provide benefits for orthotic and prosthetic appliances. 1. a. Every hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining: (1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and (2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports. 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), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., 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 P.L.2007, c.345 (C.17:48-6ff et al.), a hospital service corporation contract shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule. c. The benefits shall be provided to the same extent as for any other medical condition under the contract. d. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2007, c.345, s.1; amended 2025, c.89, s.1. 17:48-6gg Hospital service corporation to provide coverage for hearing aids, cochlear implant for covered persons. 2. a. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section. b. A hospital service corporation contract shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A hospital service corporation may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months. c. A hospital service corporation contract shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors. d. The benefits shall be provided to the same extent as for any other condition under the contract. e. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2008, c.126, s.2; amended 2023, c.275, s.1. 17:48-6hh Hospital service corporation to provide installment payments to obstetrical provider for maternity services. 1. a. Every individual or group hospital service corporation contract that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy. b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means: (1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or (2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife. c. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2009, c.113, s.1. 17:48-6ii Hospital service corporation to provide benefits for treatment of autism or other developmental disability. 1. Notwithstanding any other provision of law to the contrary, every hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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 pursuant to the provisions of this section. a. The hospital service corporation shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability. b. When the covered person's primary diagnosis is autism or another developmental disability, the hospital service corporation shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative. c. When the covered person is under 21 years of age and the covered person's primary diagnosis is autism, the hospital service corporation shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection. (1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the contract, but shall not be subject to limits on the number of visits that a covered person may make to a provider of behavioral interventions. (2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative. (3) (a) The maximum benefit amount for a covered person in any calendar year through 2011 shall be $36,000. (b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated. (c) The adjusted maximum benefit amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated. (d) Notwithstanding the provisions of this paragraph to the contrary, a hospital service corporation shall not be precluded from providing a benefit amount for a covered person in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph. d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the hospital service corporation to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The hospital service corporation may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the hospital service corporation and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances. e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to a covered person. f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share. g. The coverage required under this section may be subject to utilization review, including periodic review, by the hospital service corporation of the continued medical necessity of the specified therapies and interventions. h. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.2009, c.115, s.1. 17:48-6jj Hospital service corporation to provide coverage for oral anticancer medications. 1. a. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the contract provides for intravenously administered or injected anticancer medications. b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications. c. A hospital service corporation contract shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the contract as of the effective date of this act. d. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2011, c.188, s.1. 17:48-6kk Hospital service corporation to provide coverage for sickle cell anemia. 1. Every hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the contract provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the contract shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia. The benefits shall be provided to the same extent as for any other medical condition under the contract. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2011, c.210, s.1. 17:48-6ll Hospital service corporation to provide coverage for prescription eye drops. 1. a. A hospital service corporation which provides hospital or medical expense benefits that include coverage for prescription eye drops under a contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that: (1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and (2) the refill requested by the subscriber or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner. b. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2013, c.50, s.1. 17:48-6mm Hospital service corporation contract, coverage for synchronization of prescribed medications. 1. a. Every group or individual hospital service corporation contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan shall, on at least one occasion per year for each covered person: (1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications; (2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and (3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed. b. This section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form. L.2015, c.206, s.1. 17:48-6nn Hospital service corporation to provide benefits for treatment of substance use disorder. 1. a. A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered. b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the hospital service corporation of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, a hospital service corporation shall provide necessary exceptions to its network to ensure admission in a treatment facility within 24 hours. c. Providers of treatment for substance use disorder to persons covered under a covered contract shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the contract. d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review. e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No hospital service corporation shall initiate concurrent review more frequently than at two-week intervals. If a hospital service corporation determines that continued inpatient care in a facility is no longer medically necessary, the hospital service corporation shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The hospital service corporation shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the hospital service corporation's determination is upheld and it is determined continued inpatient care is not medically necessary, the hospital service corporation shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the contract. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider. f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services. g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the hospital service corporation and may be subject to prior authorization or, retrospective review and other utilization management requirements. h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health. i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection. k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the contract. l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section. m. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.). o. The provisions of this section shall not apply to a hospital service corporation contract which, pursuant to a contract between the hospital service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services. p. As used in this section: "Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans. "Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal. L.2017, c.28, s.1. 17:48-6oo Hospital service corporation to provide coverage regardless of gender identity, expression. 1. a. Notwithstanding any other law or regulation to the contrary, a hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the hospital service corporation shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person. b. The discrimination prohibited by this section shall include: (1) denying, cancelling, limiting or refusing to issue or renew a contract on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or (4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person: (a) health care services related to gender transition if coverage is available for those services under the contract when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or (b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition. c. For the purposes of this section: "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth. "Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth. "Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity. "Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth. d. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. e. Nothing in this section shall preclude the hospital service corporation from performing utilization review, including periodic review of the medical necessity of a particular service. L.2017, c.176, s.1. 17:48-6pp Hospital service corporation to cover digital tomosynthesis of the breast. 1. a. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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 hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2017, c.305, s.1. 17:48-6qq Hospital service corporation to provide coverage for donated human breast milk. 1. a. A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that: (1) the covered person is an infant under the age of six months; (2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health ; and (3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or (4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions: (a) a body weight below healthy levels determined by the licensed medical practitioner; (b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or (c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health. b. The provisions of this section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. c. Nothing in this section shall preclude the hospital service corporation from performing utilization review, including periodic review of the medical necessity of a particular service. d. The benefits shall be provided to the same extent as for any other prescribed items under the contract. e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the hospital service corporation shall not be required to provide coverage of expenses pursuant to this section. L.2017, c.309, s.1. 17:48-6rr Hospital service corporation to provide coverage for standard fertility preservation services. 1. a. A hospital service corporation contract which 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 hospital service corporation providing coverage under this section shall not determine the provision of standard fertility preservation services based on a covered person'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 hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2019, c.306, s.1. 17:48-6ss Hospital service corporation to provide coverage for breastfeeding support. 1. a. A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing. b. Coverage of breastfeeding equipment shall include: (1) Purchase of a single-user breast pump, subject to the following conditions: (a) A contract shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump. (b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding. (c) A contract shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph. (d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee. (e) Coverage for breast pumps shall include repair or replacement if necessary. (2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions: (a) When recommended by a licensed health care provider, a contract shall provide coverage for a multi-user breast pump. (b) A hospital service corporation may determine whether a rental or purchase is covered. (c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump. (d) A hospital service corporation may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump. (3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. (4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the hospital service corporation cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts. (5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the hospital service corporation shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment. c. Coverage of comprehensive lactation counseling and lactation consultation shall include: (1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions: (a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits. (b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need. (2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need. (3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups. (4) A contract shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) A hospital service corporation shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, a hospital service corporation shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided. e. As used in this section: "Cost-sharing" means deductible, co-insurance or co-payments, or similar charges. "Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump. "Lactation consultant" means an individual who is an International Board Certified Lactation Consultant. "Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services. Lactation care and services shall include, but not be limited to: (1) lactation assessment through the systematic collection of subjective and objective data; (2) analysis of data and creation of a plan of care; (3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider; (4) evaluation of outcomes; (5) provision of lactation education to parents and health care providers; and (6) the recommendation and use of assistive devices. "Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as: (1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding; (2) acting as an advocate for breastfeeding as the norm for feeding infants and young children; (3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals; (4) using principles of adult education when teaching clients, health care providers, and others in the community; and (5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately. "Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is: (1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or (2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication. f. This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium. L.2019, c.343, s.1. 17:48-6tt Hospital service corporation to cover preventive services. 1. a. A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, 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 hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2019, c.360, s.1. 17:48-6uu Hospital service corporation to provide certain coverage for prescription drugs. 1. a. Notwithstanding any other provision of law to the contrary, a hospital service corporation 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 corporation offers less than four plans, offered by the corporation 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) a contract 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 contract 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 contract 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 contract 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 contracts in which the hospital service corporation has reserved the right to change the premium. L.2019, c.472, s.1. 17:48-6vv Hospital service corporation contract to cover adolescent depression screenings. 1. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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 benefits shall be provided to the same extent as for any other condition under the contract, except that the hospital service corporation 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 hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. L.2021, c.73, s.1. 17:48-6ww Hospital service corporation contract to cover newborn home nurse visitation program. 5. a. No group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The contract shall: (1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159); (2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant; (3) ensure that the contract does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and (4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing: (a) a value-based payment methodology; (b) an invoice claim process; (c) a capitated payment arrangement; (d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or (e) any other payment arrangement agreed to by the hospital service corporation and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required pursuant to the contract for such services shall be waived. c. Every hospital service corporation that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program. The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161). d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section. (2) A contract offered by a group or individual hospital service corporation that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). (3) A contract offered by a group or individual hospital service corporation that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law. e. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. L.2021, c.187, s.5. 17:48-6xx Individual, group hospital service corporation contract, coverage, epinephrine auto-injector device. 2. An individual or group hospital service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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.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 hospital service corporation from reducing a subscriber'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.2. 17:48-6yy Individual, group hospital service corporation contract, coverage, prescription asthma inhaler. 3. An individual or group hospital service corporation contract providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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.2023, c.105 (C.17:48-6xx et al.) shall provide benefits to a subscriber 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 hospital service corporation from reducing a subscriber'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.3. 17:48-6zz Biomarker precision medical testing coverage, hospital service corporation contracts. 1. a. Each hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or is 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 biomarker precision medical testing, as defined by subsection g. of this section. b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of a subscriber when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for a subscriber's disease or condition is recognized by: (1) labeled indications for an FDA-approved or FDA-cleared test; (2) indicated tests for an FDA-approved drug; (3) actions to address warnings and precautions on FDA-approved drug labels; (4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or (5) nationally recognized clinical practice guidelines. c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of a subscriber. d. (1) If utilization review is required, a hospital service corporation shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The subscriber and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the subscriber shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. e. The benefits shall be provided to the same extent as for any other medical condition under the contract, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions. f. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. g. As used in this section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression. "Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care. L.2025, c.49, s.1. 17:48-6aaa Group, individual hospital service corporation contracts, HIV preexposure prophylaxis, HIV postexposure prophylaxis. 3. a. (1) Except as provided in paragraph (2) of this subsection, no group or individual hospital service corporation contract providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the contract provides benefits to any subscriber or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy. (2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the contract to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy. b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group or individual hospital service corporation contract to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria: (1) the service or procedure is within the scope of practice of the treating pharmacist; and (2) the service or procedure would otherwise be covered under the contract if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant. c. A contract offered by a group or individual hospital service corporation shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the contract to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service. d. A contract offered by a group or individual hospital service corporation shall not: (1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and (2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period. e. Nothing in this section shall be construed to require a contract offered by a group or individual hospital service corporation to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit. f. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium. g. As used in this section: �HIV preexposure prophylaxis� means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). �HIV postexposure prophylaxis� means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). �Step therapy� means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits coverage for the prophylaxis. L.2025, c.196, s.3. 17:48-6bbb Benefits provided under hospital service corporation contracts. 1. a. A hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 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.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any named subscriber or other person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to: (1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments; (2) non-hormonal treatments, including medications to manage perimenopause and menopausal symptoms; (3) behavioral health care services; (4) pelvic floor physical therapy; (5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause; (6) preventative services that have a rating of �A� or �B� in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and (7) counseling regarding menopause management. b. A hospital service corporation shall provide clear and accessible information to subscribers or covered persons regarding covered perimenopause and menopause treatments. c. The benefits shall be provided to the same extent as for any other medical condition under the contract. d. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium. e. As used in this section: �Menopause� means the permanent end of a female�s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period. �Perimenopause� means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles. L.2025, c.200, s.1.

External source: View on Justia →

This is the verbatim text of N.J.S.A. 17:48-6, retrieved from the New Jersey Legislature's public statute corpus. Statutes are amended periodically — for the most current version, check the external source link above. Kyzer is not a law firm and this page is not legal advice.