N.J.S.A. 17B:26-2.1z — Individual health insurance policies to provide benefits for orthotic and prosthetic appliances.

17B:26-2.1z Individual health insurance policies to provide benefits for orthotic and prosthetic appliances. 4. a. Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 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.), an individual health insurance policy 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 policy. d. The provisions of this section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium. L.2007, c.345, s.4; amended 2025, c.89, s.4. 17B:26-2.1aa Individual health insurance policy to provide coverage for hearing aids, cochlear implant for covered persons. 5. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, 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 policy 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. An insurer may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months. c. An individual health insurance policy 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 policy. e. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2008, c.126, s.5; amended 2023, c.275, s.4. 17B:26-2.1bb Individual health insurance policy to provide installment payments to obstetrical provider for maternity services. 4. a. Every individual health insurance policy 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 individual health insurance policies in which the insurer has reserved the right to change the premium. L.2009, c.113, s.4. 17B:26-2.1cc Individual health insurance policy to provide benefits for treatment of autism or other developmental disability. 4. Notwithstanding any other provision of law to the contrary, every individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, 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 insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability. b. When the insured's primary diagnosis is autism or another developmental disability, the insurer 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 insured is under 21 years of age and the insured's primary diagnosis is autism, the insurer 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 policy, but shall not be subject to limits on the number of visits that an insured 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 an insured 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 policy 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, an insurer shall not be precluded from providing a benefit amount for an insured 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 insurer 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 insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer 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 an insured. 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 insurer of the continued medical necessity of the specified therapies and interventions. h. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2009, c.115, s.4. 17B:26-2.1dd Individual health insurance policy to provide coverage for oral anticancer medications. 4. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:26-1 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 policy 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. An individual health insurance policy 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 policy as of the effective date of this act. d. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2011, c.188, s.4. 17B:26-2.1ee Individual health insurance policy to provide coverage for sickle cell anemia. 5. Every individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, 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 policy provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the policy 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 policy. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2011, c.210, s.5. 17B:26-2.1ff Individual health insurer to provide coverage for prescription eye drops. 4. a. An individual health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops under a policy 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 insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner. b. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2013, c.50, s.4. 17B:26-2.1gg Individual health insurance policy, contract, coverage for synchronization of prescribed medications. 4. a. Every individual health insurance policy or 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 policies in which the insurer 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.4. 17B:26-2.1hh Individual health insurance policy to provide benefits for treatment of substance use disorder. 4. a. An individual health insurance policy 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 insurer 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, an insurer shall provide necessary exceptions to their 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 policy shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the policy. 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 insurer shall initiate concurrent review more frequently than at two-week intervals. If an insurer determines that continued inpatient care in a facility is no longer medically necessary, the insurer 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 insurer 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 insurer's determination is upheld and it is determined continued inpatient care is not medically necessary, the insurer 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 policy. 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 insurer 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 policy. 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 those policies in which the insurer 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 an individual health insurance policy which, pursuant to a contract between the insurer 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.4. 17B:26-2.1ii Individual health insurance policy to provide coverage regardless of gender identity, expression. 4. a. Notwithstanding any other law or regulation to the contrary, an individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:26-1 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 insurer 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 policy 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 policy 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 those individual health insurance policies in which the insurer has reserved the right to change the premium. e. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service. L.2017, c.176, s.4. 17B:26-2.1jj Individual health insurance policy to cover digital tomosynthesis of the breast. 4. a. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 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 policy shall be applied. c. This section shall apply to those individual health insurance policies in which the insurer has reserved the right to change the premium. L.2017, c.305, s.4. 17B:26-2.1kk Individual health insurance policy to provide coverage for donated human breast milk. 4. a. An individual health insurance policy 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 policies in which the insurer has reserved the right to change the premium. c. Nothing in this section shall preclude the insurer 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 policy. e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the insurer shall not be required to provide coverage of expenses pursuant to this section. L.2017, c.309, s.4. 17B:26-2.1ll Individual health insurer to provide coverage for breastfeeding support. 4. a. An individual health insurer policy 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 policy 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 policy 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 policy shall provide coverage for a multi-user breast pump. (b) An individual health insurer 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) An individual health insurer 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 individual health insurer 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 individual health insurer 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 policy shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) An individual health insurer shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, an individual health insurer 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 policies in which the individual health insurer has reserved the right to change the premium. L.2019, c.343, s.4. 17B:26-2.1mm Individual health insurer policy to cover preventive services. 4. a. An individual health insurer policy 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 policy 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 policy 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 policy does not have in its network a provider who can provide an item or service described in subsection a. of this section, the policy 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 policy 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 policy that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year. (b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section. d. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2019, c.360, s.4. 17B:26-2.1nn Individual health insurance policy to provide certain coverage for prescription drugs. 4. a. Notwithstanding any other provision of law to the contrary, an insurer that offers an individual health insurance policy 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 carrier offers less than four plans, offered by the carrier in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), shall conform with the following: (1) (a) a policy 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 policy 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 policy 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 policy 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 policies in which the insurer has reserved the right to change the premium. L.2019, c.471, s.4. 17B:26-2.1oo Individual health insurance policy to cover adolescent depression screenings. 4. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, 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 policy, except that the insurer 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 policies in which the insurer has reserved the right to change the premium. L.2021, c.73, s.4. 17B:26-2.1pp Individual policy to cover newborn home nurse visitation. 8. a. No individual health insurance policy 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 policy provides benefits to any named insured 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 policy 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 policy 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 insurer and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required pursuant to the policy for such services shall be waived. c. An individual health insurance policy 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) An individual health insurance policy 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) An individual health insurance policy 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 policies in which the insurer has reserved the right to change the premium. L.2021, c.187, s.8. 17B:26-2.1qq Individual health insurance policy, coverage, epinephrine auto-injector device. 11. An individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes 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 an individual health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.11. 17B:26-2.1rr Individual health insurance policy, coverage, prescription asthma inhaler. 12. An individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes 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 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 an individual health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.12. 17B:26-2.1ss Biomarker precision medical testing coverage, individual health insurance policies. 4. a. Each individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes 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 an insured when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an insured's disease or condition is recognized by: (1) labeled indications for an FDA-approved or -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 an insured. d. (1) If utilization review is required, a carrier 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 insured and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the insured 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 health benefits plans in which the carrier 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.4. 17B:26-2.1tt Individual health insurance policy, HIV preexposure prophylaxis, HIV postexposure prophylaxis. 6. a. (1) Except as provided in paragraph (2) of this subsection, no individual health insurance policy 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 policy provides benefits to any named insured 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 policy 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 individual health insurance policy 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 policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant. c. An individual health insurance policy 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 policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service. d.An individual health insurance policy 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 an individual health insurance policy 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 policies in which the insurer 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.6. 17B:26-2.1uu Benefits provided under individual policies. 4. a. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S. 17B:26-1 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 insured 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 and education regarding menopause management. b. Every individual policy shall provide clear and accessible information to insureds regarding covered perimenopause and menopause treatments. c. The benefits shall be provided to the same extent as for any other medical condition under the policy. d. The provisions of this section shall apply to all health insurance policies in which the insurer 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.4.

This is the verbatim text of N.J.S.A. 17B:26-2.1z, 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.