N.J.S.A. 52:14-17.45 — Apportionment of dividend or retrospective rate credit

52:14-17.45. Apportionment of dividend or retrospective rate credit In addition to the requirements of subsection (B) of section 6 of chapter 49 of the laws of 1961, for apportionment of any dividend or retrospective rate credit declared or allowed by a carrier under a contract, the commission shall determine, in an equitable manner, (1) the amount of any such dividend or credit attributable to employee coverage provided under the program for employees of participating employers and shall credit the employer health benefits fund with such amount, and (2) the amount of any such dividend or credit attributable to dependents coverage provided under the program for employees of participating employers and shall credit such amount to the dependents premium fund. L.1964, c. 125, s. 14. 52:14-17.46a Funding of health care benefits for retirees from certain educational employment. 49. Effective July 1, 2007, health care benefits for qualified retirees and their dependents as provided by section 3 of P.L.1987, c.384 (C.52:14-17.32f), section 2 of P.L.1992, c.126 (C.52:14-17.32f1) and section 1 of P.L.1995, c.357 (C.52:14-17.32f2) shall be funded and paid by the State through a separate fund established in the Department of the Treasury. Beginning with the valuation period ending June 30, 2007, the Director of the Division of Pensions and Benefits shall annually compute a contribution to fund these health care benefits which shall be the amount necessary to pay the anticipated premiums or periodic charges for the benefits for the following valuation period and to provide that the balance in the fund as of the end of the following valuation period shall be increased by 3/5 of 1% of the salary of the active members for the valuation period. If the assets in the fund are insufficient to pay the premiums or periodic charges for the benefits, such premiums or periodic charges shall be paid directly by the State. Nothing hereinabove shall alter health care benefits for qualified retirees and their dependents or relieve the State from its acknowledged obligation to fund the benefits. L.2007, c.103, s.49. 52:14-17.46.1 Short title. 31. Sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11) shall be known and may be cited as the "School Employees' Health Benefits Program Act." L.2007, c.103, s.31. 52:14-17.46.2 Definitions relative to school employees' health benefits program. 32. As used in the School Employees' Health Benefits Program Act, sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11): a. The term "State" means the State of New Jersey. b. The term "commission" means the School Employees' Health Benefits Commission, created by section 33 of P.L.2007, c.103 (C.52:14-17.46.3). c. The term "employer" means local school district, regional school district, county vocational school district, county special services school district, jointure commission, educational services commission, State-operated school district, charter school, county college, any officer, board, or commission under the authority of the Commissioner of Education or of the State Board of Education, and any other public entity which is established pursuant to authority provided by Title 18A of the New Jersey Statutes, but excluding the State public institutions of higher education and excluding those public entities where the employer is the State of New Jersey. d. (1) The term "employee" means a person employed in any full time capacity by an employer, and shall include persons defined as a school employee by the regulations of the State Health Benefits Commission in effect on the effective date of the School Employees' Health Benefits Program Act. "Full-time" shall have the same meaning as in the regulation of the State Health Benefits Commission regarding local coverage in effect on the effective date of the School Employees' Health Benefits Program Act. (2) After the effective date of P.L.2010, c.2, the term "employee" means (a) a person employed in any full-time capacity by an employer who appears on a regular payroll and receives a salary or wages for an average of the number of hours per week as prescribed by the governing body of the participating employer which number of hours worked shall be considered full-time, determined by resolution, and not less than 25, and shall include persons defined as a school employee by the regulations of the State Health Benefits Commission in effect on the effective date of the School Employees' Health Benefits Program Act, or (b) a person employed in any full-time capacity by an employer who has or is eligible for health benefits coverage provided under P.L.1961, c.49 (C.52:14-17.25 et seq.) or sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 et seq.) on that effective date and continuously thereafter provided the person is covered by the definition in paragraph (1) of this subsection. The term "employee" shall not include persons employed on a short-term, seasonal, intermittent, or emergency basis, persons compensated on a fee basis, persons having less than two months of continuous service or persons whose compensation is limited to reimbursement of necessary expenses actually incurred in the discharge of their official duties. An employee paid on a 10-month basis, pursuant to an annual contract, shall be deemed to have satisfied the two-month waiting period if the employee begins employment at the beginning of the contract year. The term "employee" shall also not include retired persons who are otherwise eligible for benefits under the School Employees' Health Benefits Program but who, although they meet the age or disability eligibility requirement of Medicare, are not covered by Medicare Hospital Insurance, also known as Medicare Part A, and Medicare Medical Insurance, also known as Medicare Part B. A determination by the commission that a person is an eligible employee for the purposes of the School Employees' Health Benefits Program shall be final and binding on all parties. e. The term "dependents" means an employee's spouse, domestic partner, or partner in a civil union couple, and unmarried children under the age of 23 years who live in a regular parent/child relationship. "Children" shall include stepchildren, legally adopted children and children placed by the Division of Child Protection and Permanency in the Department of Children and Families, provided they are reported for coverage and are wholly dependent upon the employee for support and maintenance. A spouse, domestic partner, partner in a civil union couple, or child enlisting or inducted into military service shall not be considered a dependent during the military service. The term "dependents" shall not include spouses, domestic partners, or partners in a civil union couple, of retired persons who are otherwise eligible for the benefits under the School Employees' Health Benefits Program but who, although they meet the age or disability eligibility requirement of Medicare, are not covered by Medicare Hospital Insurance, also known as Medicare Part A, and Medicare Medical Insurance, also known as Medicare Part B. f. The term "carrier" means a voluntary association, corporation or other organization, including but not limited to a health maintenance organization as defined in section 2 of the "Health Maintenance Organizations Act," P.L.1973, c.337 (C.26:2J-2), which is lawfully engaged in providing or paying for or reimbursing the cost of, personal health services, including hospitalization, medical and surgical services under insurance policies or contracts, membership or subscription contracts, or the like, in consideration of premiums or other periodic charges payable to the carrier. g. The term "hospital" means: (1) an institution operated pursuant to law which is primarily engaged in providing on its own premises, for compensation from its patients, medical diagnostic and major surgical facilities for the care and treatment of sick and injured persons on an inpatient basis, and which provides such facilities under the supervision of a staff of physicians and with 24 hour a day nursing service by registered graduate nurses, or (2) an institution not meeting all of the requirements of paragraph (1) but which is accredited as a hospital by the Joint Commission on Accreditation of Hospitals. In no event shall the term "hospital" include a convalescent nursing home or any institution or part thereof which is used principally as a convalescent facility, residential center for the treatment and education of children with mental disorders, rest facility, nursing facility or facility for the aged or for the care of persons with substance use disorder. h. The term "Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L.89-97 (42 U.S.C. s.1395 et seq.), as amended, or its successor plan or plans. i. The term "managed care plan" means a health care plan under which comprehensive health care services and supplies are provided to eligible employees, retirees, and dependents: (1) through a group of doctors and other providers employed by the plan; or (2) through an individual practice association, preferred provider organization, or point of service plan under which services and supplies are furnished to plan participants through a network of doctors and other providers under contracts or agreements with the plan on a prepayment or reimbursement basis and which may provide for payment or reimbursement for services and supplies obtained outside the network. The plan may be provided on an insured basis through contracts with carriers or on a self-insured basis, and may be operated and administered by the State or by carriers under contracts with the State. j. The term "successor plan" means a managed care plan that shall replace the "traditional plan," as defined in section 2 of P.L.1961, c.49 (C.52:14-17.26), and that shall provide benefits as set forth in section 36 of P.L.2007, c.103 (C.52:14-17.46.6), and provide out-of-network benefits to participants with a payment by the plan of 80 percent of reasonable and customary charges as set forth in section 37 of P.L.2007, c.103 (C.52:14-17.46.7) and as may be adjusted in accordance with section 40 of P.L.2007, c.103 (C.52:14-17.46.10). L.2007, c.103, s.32; amended 2010, c.2, s.10; 2023, c.177, s.140. 52:14-17.46.3 School Employees' Health Benefits Commission, School Employees' Health Benefits Plan Design Committee. 33. a. There is hereby created a School Employees' Health Benefits Commission, consisting of nine members: (1) the State Treasurer and the Commissioner of the Department of Banking and Insurance serving ex officio; (2) a member appointed by the Governor who is a New Jersey resident and is qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers; (3) a member appointed by the Governor from among three persons nominated by the New Jersey School Boards' Association, which member shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers; (4) three members appointed by the Governor from among five persons nominated by the New Jersey Education Association, of whom two shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers; (5) a member appointed by the Governor from among three persons nominated by the education section of the New Jersey State AFL-CIO, which member shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers; and (6) a member appointed pursuant to subsection b. of this section who shall be the chairperson. b. The Governor shall appoint the chairperson from among three persons nominated jointly by at least six of the eight members appointed pursuant to subsection a. of this section. c. If the Governor declines to make an appointment from among the persons nominated for membership, the Governor shall request that a new list of nominees be provided in compliance with subsection a. of this section. If the Governor declines to make an appointment from the new list, the process set forth in this subsection shall be repeated until the Governor makes an appointment from a list of nominees. Except with respect to the appointment of the chairperson, if a new list of nominees is not submitted within 45 days of the Governor's request, the Governor shall make the appointment without the need to select from any list of nominees. d. The initial terms of the members of the commission shall be as follows: (1) the member appointed pursuant to paragraph (3) of subsection a. of this section and the two members appointed pursuant to paragraph (4) of subsection a. of this section who are required to be qualified by experience, education, or training shall serve for a term of three years; (2) the member appointed pursuant to paragraph (2) of subsection a. of this section, the member appointed pursuant to paragraph (4) of subsection a. of this section who is not required to be qualified by experience, education, or training, and the member appointed pursuant to paragraph (5) of subsection a. of this section shall serve for a term of two years; and (3) the chairperson shall serve for a term of six years. All subsequent terms shall be for three years, except that the term of the chairperson shall be five years. A member of the commission may be reappointed to succeeding terms without limit in the same manner as the original appointment. A vacancy occurring on the commission shall be filled in the same manner as the original appointment and only for the unexpired term. e. There is established a School Employees' Health Benefits Plan Design Committee, composed of six members as follows: three members who shall be appointed by the Governor as representatives of public employers whose employees are enrolled in the program; two members who shall be appointed by the New Jersey Education Association; and one member who shall be appointed by the education section of the New Jersey State AFL-CIO. The members of the committee shall serve for a term of three years and until a successor is appointed and qualified. Of the initial appointments by the Governor, two members shall serve for two years and until a successor is appointed and qualified, and one shall serve for one year and until a successor is appointed and qualified. Of the initial appointments by the New Jersey Education Association, one member shall serve for one year and until a successor is appointed and qualified. The members of the committee shall select a chairperson from among the members, who shall serve for a term of one year, with no member serving more than one term as chairperson until all the members of the committee have served a term in a manner alternating among the employer representatives and employee representatives, unless the committee determines otherwise with regard to this process. The committee shall have the responsibility for and authority over the various plans and components of those plans, including for medical benefits, prescription benefits, dental, vision, and any other health care benefits, offered and administered by the program. The committee shall have the authority to create, modify, or terminate any plan or component, at its sole discretion. Any reference in law to the School Employees' Health Benefits Commission in the context of the creation, modification, or termination of a plan or plan component shall be deemed to apply to the committee. The members of the committee shall have the same duty and responsibility to the program as do the members of the commission. If any matter before the committee receives at least four votes in the affirmative, the commission shall approve and implement the committee's decision. If any matter before the committee receives three votes in the affirmative and three votes in the negative or the committee otherwise reaches an impasse on a decision, the provisions of section 55 of P.L.2011, c.78 (C.52:14-17.27b) shall be followed. L.2007, c.103, s.33; amended 2011, c.78, s.46. 52:14-17.46.4 Administration of School Employees' Health Benefits Program. 34. The School Employees' Health Benefits Program, authorized by sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11), shall be administered in the Department of the Treasury. Administrative services required by the commission shall be provided through the Division of Pensions and Benefits, and the Director of the Division of Pensions and Benefits shall be the secretary of the commission. The commission and the committee shall establish a health benefits program for the school employees of the State, the cost of which shall be paid as specified in this act. The commission shall, by a majority vote of its full authorized membership, establish and change rules and regulations as may be deemed reasonable and necessary for the administration of this act by the commission and committee. Until such rules and regulations are established, the rules and regulations of the State Health Benefits Commission shall be deemed to apply to the School Employees' Health Benefits Program. The Attorney General shall be the legal advisor of the commission and committee. The members of the commission and committee shall serve without compensation but shall be reimbursed for any necessary expenditure. The commission shall ensure that audits and reviews are performed as required by section 40 of P.L.2007, c.103 (C.52:14-17.46.10). Actions of the commission related to such audits and reviews shall require a majority vote of the full authorized membership of the commission to be approved. Except as otherwise specified in this act, actions of the commission shall require the affirmative vote of a majority of the members present at a meeting at which a majority of the full authorized membership is present. L.2007, c.103, s.34; amended 2011, c.78, s.36. 52:14-17.46.5 Purchase of contracts providing benefits. 35. a. The commission shall negotiate with and arrange for the purchase, on such terms as it deems in the best interests of the State, participating employers and those persons covered hereunder from carriers licensed to operate in the State or in other jurisdictions, as appropriate, contracts providing benefits required by the School Employees' Health Benefits Program Act, as specified in section 36 of P.L.2007, c.103 (C.52:14-17.46.6), or such benefits as the commission may determine to provide, so long as such modification of benefits is in the best interests of the State, participating employers and those persons covered hereunder, and is consistent with the provisions of section 40 of that act (C.52:14-17.46.10). The commission shall have authority to execute all documents pertaining thereto for and on behalf of the State. The commission shall not enter into a contract under the School Employees' Health Benefits Program Act, unless the benefits provided thereunder are equal to or exceed the standards specified in section 36 of that act, or as such standards are modified pursuant to section 40 of that act. b. The rates charged for any contract purchased under the authority of the School Employees' Health Benefits Program Act shall reasonably and equitably reflect the cost of the benefits provided based on principles which in the judgment of the commission are actuarially sound. The rates charged shall be determined based upon accepted group rating principles with due regard to the experience, both past and contemplated, under the contract. The commission shall have the right to particularize subgroups for experience purposes and rates. No increase in rates shall be retroactive. c. The commission shall be authorized to accept an assignment of contract rights from or enter into an agreement, contract, memorandum of understanding or other terms with the State Health Benefits Commission to ensure that coverage for eligible employees, retirees and dependents under the School Employees' Health Benefits Program whose benefits had been provided through the State Health Benefits Program is continued without interruption. The transition provided for in this subsection shall occur within one year of the effective date of the School Employees' Health Benefits Program Act, sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11). d. Benefits under the contract or contracts purchased as authorized by the School Employees' Health Benefits Program Act may be subject to such limitations, exclusions, or waiting periods as the commission finds to be necessary or desirable to avoid inequity, unnecessary utilization, duplication of services or benefits otherwise available, including coverage afforded under the laws of the United States, such as the federal Medicare program, or for other reasons. e. The initial term of any contract purchased by the commission under the authority of the School Employees' Health Benefits Program Act shall be for such period to which the commission and the carrier may agree, but permission may be made for automatic renewal in the absence of notice of termination by the commission. Subsequent terms for which any contract may be renewed as herein provided shall each be limited to a period not to exceed one year. f. Any carrier with which the commission contracts for the provision of hospital, surgical, obstetrical, and other covered health care services and benefits pursuant to this section shall provide to the third-party medical claims reviewer, procured pursuant to section 2 of P.L.2019, c.143 (C.52:14-17.30b), information in that carrier's provider network contracts, such as claims information and contractual discounts provided thereunder, that are applicable to a health benefits plan offered under the School Employees' Health Benefits Program. Documents, materials and other information in the possession or control of the State, or the third-party medical claims reviewer, that are obtained or created by, or disclosed to, the State or any other person pursuant to this subsection shall be recognized by this State as being proprietary and containing trade secrets. All such documents, materials or other information shall be confidential by law and privileged, and shall not be subject to P.L.1963, c.71 (C.47:1A-1 et seq.); except that the State is authorized to use the documents, materials or other information in the furtherance of any regulatory or legal action brought as a part of the commission's or third-party medical claims reviewer's official duties. The State and the third-party medical claims reviewer shall not disclose, sell, or transfer the documents, materials or other information without the prior written consent of the carrier. This subsection shall not be construed as pertaining to medical claims data. g. A contract entered into with a carrier pursuant to this section shall include therein the State's existing right to withhold payment for administrative services or to pursue any other remedy deemed appropriate by the State Treasurer if the carrier is found by the State upon information provided by the third-party medical claims reviewer to have committed errors resulting in a loss to the State in a quantity or value, or both, beyond a certain threshold, as shall be provided in the contract or by rules promulgated by the State Treasurer. The contract shall permit the State to recover any loss resulting from errors identified by the third-party medical claims reviewer. h. Information provided to or obtained by the third-party medical claims reviewer shall be delivered, received, maintained, and reviewed in a manner and shall contain only material consistent with the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191. To the extent necessary in accordance therewith, a carrier shall ensure that information provided to the medical claims reviewer is attendant to only persons who are participants in the School Employees' Health Benefits Program. L.2007, c.103, s.35; amended 2019, c.143, s.5. 52:14-17.46.5a Definitions. 4. The definitions set forth in section 32 of P.L.2007, c.103 (C.52:14-17.46.2) shall be applicable to sections 4 and 5 of this act, P.L.2023, c.195 (C.52:14-17.46.5a and 52:14-17.46.5b). In addition, as used in this act: "Competitive range" means the group of responsive proposals to a request for proposal that are among the most highly rated proposals as determined by the evaluation committee. The commission, or its designee, shall include an economic component to the established competitive range to ensure the group of responsive proposals deliver competitive pricing beneficial to the State Health Benefits Program and the School Employees' Health Benefits Program. "Early retiree" means a retired employee of the State or participating employer who is retired, under 65 years of age, and not yet eligible to enroll in Medicare. "Evaluation committee" means a group of individuals assigned, pursuant to section 3 of P.L.2005, c.336 (C.52:34-10.3), to review and evaluate quotes submitted in response to a request for proposal and recommend a contract award. "Medicare retiree" means a retired employee of the State or participating employer who is 65 years of age or older, or otherwise qualified to enroll in Medicare due to health status, and is currently enrolled in Medicare. Eligible retirees include those who are enrolled in a self-insured Medicare Supplement plan. "Plan type" means preferred provider organization (PPO), health maintenance organization (HMO), tiered network plan, high-deductible health plan, and Medicare supplemental PPO and HMO plans as those terms may be defined in law. "Request for proposal" refers to all documents, whether attached or incorporated by reference, used for a publicly advertised procurement process that solicits proposals or offers to provide the goods or services specified therein. "Responsive proposal" refers to a proposal that is deemed to have adequately addressed all material provisions of a request for proposal's terms and conditions, specifications, and other requirements. "Third-party administrator" means a vendor that conducts claims administration, network management, claims processing, or other related services for an organization contracted by the State to provide health care services and benefits. L.2023, c.195, s.4. 52:14-17.46.5b School Employees' Health Benefits Commission, third-party administrators, responsive proposals, advantageous to the State. 5. a. For each plan type offered to eligible employees, early retirees, and certain Medicare retirees, and their dependents, the School Employees' Health Benefits Commission, or its designee, shall select at least two third-party administrators from among those vendors who submit responsive proposals that are most advantageous to the State, price and other factors considered, provided that, if fewer than two vendors submit responsive proposals within a competitive range established by the evaluation committee, the commission, or its designee, shall either: (1) select the one qualified vendor; or (2) reissue the solicitation for the plan type in its entirety in an effort to secure at least two third-party administrators. b. Unless otherwise limited through the terms of a collective bargaining agreement, State or federal statute, or regulation, an eligible employee, early retiree, and Medicare retirees not eligible for or enrolled in Medicare Advantage plans shall have the opportunity, on an annual basis, during the open enrollment period or other applicable enrollment period, to choose a plan from among the plan types the commission has selected. c. The commission, or its designee, shall award the contracts for each plan type under subsection a. of this section on the basis of the bid responses that are the most advantageous to the State, which shall consider price, network breadth, member experience, the ability to engage in innovative approaches designed to slow the growth of health care costs, and any other factors that the commission or its designee may deem relevant. d. The commission, or its designee, is authorized to award a contract to the vendor with the bid that is most advantageous to the State, price and other factors considered, based upon the evaluation factors in subsection c. of this section, and to thereafter award another contract to one or more vendors with bids within the competitive range that can provide a comparable bid price and factors of the first awarded contract. L.2023, c.195, s.5. 52:14-17.46.6 Benefits required for coverage under contract; terms defined. 36. a. Notwithstanding the provisions of any other law to the contrary, the commission shall not enter into a contract under the School Employees' Health Benefits Program Act, sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11), for the benefits provided pursuant to the act, unless the level of benefits provided under the contract entered into is equal to or exceeds the level of benefits provided in this section, or as modified pursuant to section 40 of that act (C.52:14-17.46.10). Only benefits for medically necessary services that are not deemed experimental, investigative or otherwise not eligible medical services shall be provided. The determination that services are not "eligible medical services" shall be made by the commission consistent with the best interests of the State, participating employers and those persons covered hereunder. Benefits for services provided pursuant to the School Employees' Health Benefits Act shall be subject to limits or exclusions consistent with those that apply to benefits provided pursuant to the New Jersey State Health Benefits Program Act. The services provided pursuant to this section shall include all services, subject to applicable limits and exclusions, provided through the State Health Benefits Program as of July 1, 2007. The list of services in subsection b. of this section is not intended to be exclusive or to require that any limits or exclusions be exceeded. b. The services covered hereunder by the School Employees' Health Benefits Program shall include: (1) Physician services, including: (a) Inpatient services, including: (i) medical care including consultations; (ii) surgical services and services related thereto; and (iii) obstetrical services including normal delivery, cesarean section, and abortion. (b) Outpatient/out-of-hospital services, including: (i) office visits for covered services and care; (ii) allergy testing and related diagnostic/therapy services; (iii) dialysis center care; (iv) maternity care; (v) well child care; (vi) child immunizations/lead screening; (vii) routine adult physicals including pap, mammography, and prostate examinations; and (viii) annual routine obstetrical/gynecological exam. (2) Hospital services, both inpatient and outpatient, including: (a) room and board; (b) intensive care and other required levels of care; (c) semi-private room; (d) therapy and diagnostic services; (e) surgical services or facilities and treatment related thereto; (f) nursing care; (g) necessary supplies, medicines, and equipment for care; and (h) maternity care and related services. (3) Other facility and services, including: (a) approved treatment centers for medical emergency/accidental injury; (b) approved surgical center; (c) hospice; (d) chemotherapy; (e) diagnostic x-ray and lab tests; (f) ambulance; (g) durable medical equipment; (h) prosthetic devices; (i) foot orthotics; (j) diabetic supplies and education; and (k) oxygen and oxygen administration. c. Benefits under the contract or contracts purchased as authorized by the School Employees' Health Benefits Program Act shall include those for the treatment of alcohol use disorder where such treatment is prescribed by a physician and shall also include treatment while confined in or as an outpatient of a licensed hospital or residential treatment program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation. No benefits shall be provided beyond those stipulated in the contracts held by the School Employees' Health Benefits Commission. d. Benefits under the contract or contracts purchased as authorized by the School Employees' Health Benefits Program Act shall include those for mental health services subject to limits and exclusions consistent with those that apply to benefits for such services pursuant to the New Jersey State Health Benefits Program Act. Coverage for biologically-based mental illness, as defined in section 1 of P.L.1999, c.441 (C.52:14-17.29d), shall be provided in accordance with section 2 of P.L.1999, c.441 (C.52:14-17.29e). e. Coverage provided under the School Employees' Health Benefits Program Act shall include coverage for all services for which coverage is mandated in the State Health Benefits Program pursuant to P.L.1961, c.49 (C.52:14-17.25 et seq.). f. (1) As used in this subsection: (a) "brand name" means the proprietary or trade name assigned to a drug product by the manufacturer or distributor of the drug product. (b) "carrier" means an insurance company, hospital, medical, or health service corporation, preferred provider organization, or health maintenance organization under agreement or contract with the commission to administer the School Employee Prescription Drug Plan. (c) "School Employee Prescription Drug Plan" means the plan for providing payment for eligible prescription drug expenses of members of the School Employees' Health Benefits Program and their eligible dependents. (d) "generic drug products" means prescription drug products and insulin approved and designated by the United States Food and Drug Administration as therapeutic equivalents for reference listed drug products. The term includes drug products listed in the New Jersey Generic Formulary by the Drug Utilization Review Council pursuant to P.L.1977, c.240 (C.24:6E-1 et al.). (e) "mail-order pharmacy" means the mail order program available through the carrier. (f) "preferred brands" means brand name prescription drug products and insulin determined by the carrier to be a more cost effective alternative for prescription drug products and insulin with comparable therapeutic efficacy within a therapeutic class, as defined or recognized in the United States Pharmacopeia or the American Hospital Formulary Service Drug Information, or by the American Society of Health Systems Pharmacists. A drug product for which there is no other therapeutically equivalent drug product shall be a preferred brand. Determinations of preferred brands by the carrier shall be subject to review and modification by the commission. (g) "retail pharmacy" means a pharmacy, drug store or other retail establishment in this State at which prescription drugs are dispensed by a registered pharmacist under the laws of this State, or a pharmacy, drug store or other retail establishment in another state at which prescription drug products are dispensed by a registered pharmacist under the laws of that state if expenses for prescription drug products dispensed at the pharmacy, drug store, or other retail establishment are eligible for payment under the School Employee Prescription Drug Plan. (h) "other brands" means prescription drug products which are not preferred brands or generic drug products. A new drug product approved by the United States Food and Drug Administration which is not a generic drug product shall be included in this category until the carrier makes a determination concerning inclusion of the drug product in the list of preferred brands. (2) (a) Employers that participate in the School Employees' Health Benefits Program may offer to their employees and eligible dependents: (i) enrollment in the School Employee Prescription Drug Plan, or (ii) enrollment in another free-standing prescription drug plan, or (iii) election of prescription drug coverage under their health care coverage through the School Employees' Health Benefits Program plan or as otherwise determined by the commission. (b) A co-payment shall be required for each prescription drug expense if the employer chooses to participate in the School Employee Prescription Drug Plan. The initial amounts of the co-payments shall be the same as those in effect on July 1, 2007 for the employee prescription drug plan offered through the State Health Benefits Program. (c) If the employer elects to offer a free-standing prescription drug plan, the employee's share of the cost for this prescription drug plan may be determined by means of a binding collective negotiations agreement, including any agreements in force at the time the employer commences participation in the School Employees' Health Benefits Program. (d) If an employee declines the employer's offering of a free-standing prescription drug plan, no reimbursement for prescription drugs shall be provided under the health care coverage through the School Employees' Health Benefits Program plan in which the employee is enrolled. (e) Prescription drug classifications that are not eligible for coverage under the employer's prescription drug plan shall also not be eligible for coverage under the health care coverage through the School Employees' Health Benefits Program plan except as federally or State mandated. (f) If the employer elects to not offer a free-standing prescription drug plan, then the employer shall offer prescription drug coverage under the health care coverage through the School Employees' Health Benefits Program plan or as determined by the commission. Any plan that has in-network and out-of-network coverage shall cover prescription drugs at 90 percent in-network and at the out-of-network rate applicable to health care coverage in the plan. The out-of-pocket amounts paid towards prescription drugs shall be combined with out-of-pocket medical payments to reach all out-of-pocket maximums. (g) Health care coverages through the School Employees' Health Benefits Program that only have in-network benefits shall include a prescription card with co-payment amounts the same as those in effect on July 1, 2007 for such coverages offered through the State Health Benefits Program. (h) In the fifth year following the initial appointment of all of its members, the commission shall, as part of the fifth year audit and review undertaken pursuant to section 40 of that act (C.52:14-17.46.10), review the prescription drug program established in this subsection and may make changes in the program pursuant to the terms of section 40 by majority vote of the full authorized membership of the commission. g. Beginning January 1, 2012, the School Employees' Health Benefits Plan Design Committee shall provide to employees the option to select one of at least three levels of coverage each for family, individual, individual and spouse, and individual and dependent, or equivalent categories, for each plan offered by the program differentiated by out of pocket costs to employees including co-payments and deductibles. Notwithstanding any other provision of law to the contrary, the committee shall have the sole discretion to set the amounts for maximums, co-pays, deductibles, and other such participant costs for all plans in the program. The committee shall also provide for a high deductible health plan that conforms with Internal Revenue Code Section 223. There shall be appropriated annually for each State fiscal year, through the annual appropriations act, such amounts as shall be necessary as funding by the State with regard to retirees who have enrolled in a high deductible health plan that conforms with Internal Revenue Code Section 223. L.2007, c.103, s.36; amended 2011, c.78, s.48; 2023, c.177, s.141. 52:14-17.46.6a School Employees' Health Benefits Commission to provide for installment payments to obstetrical provider for maternity services. 10. Within 30 days of the effective date of this act, the School Employees' Health Benefits Commission shall provide, in every health benefits plan that provides for maternity services, 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. L.2009, c.113, s.10. 52:14-17.46.6b School Employees' Health Benefits program to provide benefits for treatment of autism or other developmental disability. 10. Notwithstanding any other provision of law to the contrary, the School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage pursuant to the provisions of this section. a. The contract 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 contract 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 contract 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, the commission 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 carrier 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 carrier may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the carrier 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 carrier of the continued medical necessity of the specified therapies and interventions. L.2009, c.115, s.10. 52:14-17.46.6c School Employees' Health Benefits Commission to provide coverage for oral anticancer medications. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act that provides hospital or medical expense benefits 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 School Employees' Health Benefits Commission 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. L.2011, c.188, s.10. 52:14-17.46.6d School Employees' Health Benefits Commission to provide coverage for prescription eye drops. 10. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits that include coverage for prescription eye drops, 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 covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner. L.2013, c.50, s.10. 52:14-17.46.6e School Employees' Health Benefits Commission, coverage for synchronization of prescribed medications. 10. The School Employees' Health Benefits Commission shall ensure that every contract under the School Employees' Health Benefits Program purchased 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. 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.10. 52:14-17.46.6f School Employees' Health Benefit Commission to provide benefits for treatment of substance use disorder. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act provides 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 benefit payer 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, the contract 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 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 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. The contract shall not initiate concurrent review more frequently than at two-week intervals. If it is determined that continued inpatient care in a facility is no longer medically necessary, the contract shall provide that within 24 hours, written notice shall be provided 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. A determination shall be made with respect to the internal appeal within 24 hours and shall be communicated 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 determination is upheld and it is determined continued inpatient care is not medically necessary, the contract shall state that benefits are provided 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 medical necessity determination 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. 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.10. 52:14-17.46.6g School Employees Health Benefits Program to provide coverage for treatment of infertility. 7. The School Employees Health Benefits Commission shall ensure that every contract under the School Employees Health Benefits Program shall provide coverage for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The School Employees Health Benefits Program 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 School Employees Health Benefits Commission 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 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 under the contract 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. Nothing in this section shall preclude the carrier 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.2017, c.48, s.7; amended 2023, c.258, s.7. 52:14-17.46.6h School Employees Health Benefits Commission to provide coverage, payment. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased thereby, which provides hospital and medical expense benefits, additionally provides coverage and payment for health care services delivered to a covered person through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered under the contract when delivered through in-person contact and consultation in New Jersey. Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate. b. A health benefits contract purchased by the School Employees' Health Benefits Commission may limit coverage to services that are delivered by health care providers in the health benefits plan's network, but may not charge any deductible, copayment, or coinsurance for a health care service, delivered through telemedicine or telehealth, in an amount that exceeds the deductible, copayment, or coinsurance amount that is applicable to an in-person consultation. In no case shall a health benefits contract purchased by the School Employees' Health Benefits Commission: (1) impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person; (2) restrict the ability of a provider to use any electronic or technological platform to provide services using telemedicine or telehealth, including, but not limited to, interactive, real-time, two-way audio, which may be used in combination with asynchronous store-and-forward technology without video capabilities, including audio-only telephone conversations, to provide services using telemedicine or telehealth, provided that the platform used: (a) allows the provider to meet the same standard of care as would be provided if the services were provided in person; and (b) is compliant with the requirements of the federal health privacy rule set forth at 45 CFR Parts 160 and 164; (3) deny coverage for or refuse to provide reimbursement for routine patient monitoring performed using telemedicine and telehealth, including remote monitoring of a patient's vital signs and routine check-ins with the patient to monitor the patient's status and condition, if coverage and reimbursement would be provided if those services are provided in person, and the provider is able to meet the same standard of care as would be provided if the services were provided in person; or (4) limit coverage only to services delivered by select third-party telemedicine or telehealth organizations. c. Nothing in this section shall be construed to: (1) prohibit a health benefits contract from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the covered person's health benefits plan; or (2) allow the School Employees' Health Benefits Commission, or a contract purchased thereby, to require a covered person to use telemedicine or telehealth in lieu of receiving an in-person service from an in-network provider. d. The School Employees' Health Benefits Commission shall adopt rules and 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. e. As used in this section: "Asynchronous store-and-forward" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Distant site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Originating site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telehealth" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine or telehealth organization" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). L.2017, c.117, s.10; amended 2021, c.310, s.6. 52:14-17.46.6i School Employees' Health Benefits Commission to provide coverage regardless of gender identity, expression. 10. a. Notwithstanding any other law or regulation to the contrary, the School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall not contain any provision that discriminates, and the commission shall ensure there is no discrimination, 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. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service. L.2017, c.176, s.10. 52:14-17.46.6j School Employees' Health Benefits Commission to cover digital tomosynthesis of the breast. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits 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. L.2017, c.305, s.10. 52:14-17.46.6k School Employees' Health Benefits Commission to provide coverage for donated human breast milk. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits 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. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service. c. The benefits shall be provided to the same extent as for any other prescribed items under the contract. d. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the carrier shall not be required to provide coverage of expenses pursuant to this section. L.2017, c.309, s.10. 52:14-17.46.6l School Employees' Health Benefits Commission not to provide coverage for certain early elective deliveries. 5. a. Notwithstanding any other law or regulation to the contrary, the School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital and medical expense benefits shall not provide coverage for a non-medically indicated early elective delivery performed at a hospital on a pregnant woman earlier than the 39th week of gestation. b. As used in this section, "non-medically indicated early elective delivery" means the artificial start of the birth process through medical interventions or other methods, also known as labor induction, or the surgical delivery of a baby via a cesarean section for purposes or reasons that are not fully consistent with established standards of clinical care as provided by the American College of Obstetricians and Gynecologists. L.2019, c.87, s.5. 52:14-17.46.6m School Employees' Health Benefits Commission to provide coverage for standard fertility preservation services. 7. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits 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. The School Employees' Health Benefits Program shall not purchase a contract that determines 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. L.2019, c.306, s.7. 52:14-17.46.6n School Employees' Health Benefits Commission to provide coverage for breastfeeding support. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits 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 contract 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 contract 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 contract 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 contract may provide for a determination as to 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 contract may provide for requirement of 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 enrollee does not receive breastfeeding equipment within 48 hours, the enrollee may purchase the equipment and the contract shall provide for reimbursement of 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 contract shall provide for reimbursement of all out-of-pocket rental expenses incurred by the 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 contract shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, a contract 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. L.2019, c.343, s.10. 52:14-17.46.6o School Employee's Health Benefits Commission to cover preventive services. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits 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. L.2019, c.360, s.10. 52:14-17.46.6p School Employees' Health Benefits Commission to cover adolescent depression screenings. 10. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission, on or after the effective date of this act, that provides hospital or medical expense benefits 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 contract shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance. L.2021, c.73, s.10. 52:14-17.46.6q School Employees' Health Benefits Commission, coverage for abortion, certain religious employers exemption. 5. A contract providing hospital or medical expense benefits purchased by the School Employees' Health Benefits Commission may provide coverage for abortion. A contract providing hospital or medical expense benefits purchased by the commission shall not exclude a provider from its network or otherwise restrict services from the provider solely on the basis that the provider is a religious employer, as defined in section 3 of P.L.2021, c.375 (C.26:2S-39), that refuses to provide abortion services. L.2021, c.375, s.5. 52:14-17.46.6r The School Employees' Health Benefits Commission, contract, provide coverage for colorectal cancer screening. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits shall provide benefits to any person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recent 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. L.2023, c.8, s.10. 52:14-17.46.6s School Employees' Health Benefits Commission, ensure, contract purchased, health care services, insulin for diabetes treatment. 28. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) that provides hospital and medical expense benefits shall provide health care services to a person covered thereunder for insulin for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply, except a contract provided by the School Employees' Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of insulin 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 (c)(2)(A)). 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 the School Employees' Health Benefits Commission from reducing an enrollee's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.28. 52:14-17.46.6t School Employees' Health Benefits Commission, ensure, contract purchased, renewed, coverage, epinephrine auto-injector device. 29. The School Employees' Health Benefits Commission shall ensure that every contract purchased or renewed by the commission 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, except a contract provided by the School Employees' Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of an epinephrine auto-injector device 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 (c)(2)(A)). 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 the School Employees' Health Benefits Commission from reducing an enrollee's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.29. 52:14-17.46.6u School Employees' Health Benefits Commission, ensure, contract purchased, renewed, benefits, covered, expenses, prescription asthma inhaler. 30. The School Employees' Health Benefits Commission shall ensure that every contract purchased or renewed by the commission 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, except a contract provided by the School Employees' Health Benefits Commission that qualifies as a high-deductible health plan shall provide coverage for the purchase of a covered prescription asthma inhaler 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 (c)(2)(A)). 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 the School Employees' Health Benefits Commission from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section or prevent the commission from utilizing formulary management, including a mandatory generic policy, to promote the use of lower-cost alternative generic drugs that are the therapeutic equivalent of the brand-name drug, which could result in the member's copay being higher than set forth in this section. L.2023, c.105, s.30. 52:14-17.46.6v School Employees' Health Benefits Commission, coverage, hearing aid, cochlear implant purchase, covered persons. 11. a. The School Employees' Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act provides benefits 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. The benefits shall include the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. The commission may limit the benefit provided in this section to $2,500 per hearing aid for each hearing-impaired ear every 60 months. c. The benefits 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. L.2023, c.275, s.11. 52:14-17.46.6w Biomarker precision medical testing coverage, School Employees' Health Benefits Commission contracts. 10. a. The School Employees' Health Benefits Commission shall ensure that every contract providing hospital or medical expense benefits, which is purchased by the commission on or after the effective date of this act, provides coverage for biomarker precision medical testing, as defined by subsection e. 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 covered person when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for a covered person'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 a covered person. d. (1) If utilization review is required, a decision shall be rendered pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The covered person and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the covered person shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. e. 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.10. 52:14-17.46.6x Benefits provided under contracts purchased by the School Employee�s Health Benefits Commission. 10. a. The School Employees� Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), that provides hospital or medical expense benefits shall provide benefits to any 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 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. The School Employees Health Benefits Commission shall ensure that each contract shall provide clear and accessible information to a covered person 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. 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.10. 52:14-17.46.7 Offer of managed care plan, terms. 37. Beginning with the initial year of the School Employees' Health Benefits Program, the commission shall offer to participating employers and to qualified employees, retirees and dependents a managed care plan in which the office co-payment amount shall be $10 per visit with a maximum out-of-pocket of $400 per individual and $1,000 per family for in-network services for each calendar year. The out-of-network deductible shall be $100 per individual and $250 per family for each calendar year with the plan paying for 80% of reasonable and customary charges as defined herein up to an out-of-pocket maximum that shall not exceed $2,000 per individual and $5,000 per family for each calendar year. In the successor plan, the in-network out-of-pocket payments shall count toward the out-of-network out-of-pocket maximums. Any lifetime maximum for out-of-network services shall not be less than any maximums in effect under the State Health Benefits Program as of July 1, 2007. There shall be no lifetime maximum for in-network services. The carrier that administers the successor plan shall make available to the plan participants through in-network and out-of-network providers access to physicians and hospitals sufficient in geographic scope and number to provide access to health care services that is substantially equivalent to the access to health care services available through the State Health Benefits Program as of July 1, 2007. Beginning with the initial year of the School Employees' Health Benefits Program, the commission shall be authorized to offer to participating employers and qualified employees, retirees and dependents managed care plans in which the in-network per visit charge shall not exceed $15 per visit and the out of network reimbursement shall be 70% of reasonable and customary charges as defined herein, provided the in-network and out-of-network maximums and deductibles do not exceed the limits set forth above. The amounts of maximums, co-pays, deductibles, and other participant costs shall be reviewed, as part of the fifth year audit undertaken pursuant to section 40 of P.L.2007, c.103 (C.52:14-17.46.10). The commission shall make changes in such amounts pursuant to section 40 by majority vote of the full authorized membership of the commission. Beginning January 1, 2012, the School Employees' Health Benefits Plan Design Committee shall have the sole discretion to set the amounts for maximums, co-pays, deductibles, and other such participant costs for all plans offered in the program, notwithstanding any other provision of law to the contrary. "Reasonable and customary charges" means, for any out-of-network payment made by a carrier, charges based upon the 90th percentile of the usual, customary, and reasonable (UCR) fee schedule determined by the Health Insurance Association of America or a similar nationally recognized database of prevailing health care charges. Beginning with the initial year of the School Employees' Health Benefits Program, the commission shall offer to participating employers and qualified employees, retirees and dependents one or more health maintenance organization plans. L.2007, c.103, s.37; amended 2011, c.78, s.49. 52:14-17.46.8 Participation in School Retiree Prescription Drug Plan, terms. 38. a. Retirees and eligible dependents who participate in the School Employees' Health Benefits Program shall be eligible to participate in the School Retiree Prescription Drug Plan. The definitions in subsection f. of section 36 of P.L.2007, c.103 (C.52:14-17.46.6) shall apply to the School Retiree Prescription Drug Plan. b. There shall be no annual deductible amount that retirees or their eligible dependents shall be required to satisfy before eligibility for payment of prescription drug expenses under the School Retiree Prescription Drug Plan. c. Eligibility of prescription drug expenses for coverage under the School Retiree Prescription Drug Plan shall be determined on the same basis as reasonable and necessary medical expenses under the School Employees' Health Benefits Program. d. A co-payment shall be required for each prescription drug expense until a retiree or eligible dependent satisfies the maximum annual out-of-pocket expense for a calendar year prescribed in subsection f. of this section. The amounts of the co-payments shall be the same as those in effect as of July 1, 2007 for retiree prescription drug coverage under the State Health Benefits Program. The commission shall promulgate rules that shall establish a formula for a reasonable annual escalator to the amount of co-payment. e. The supply of a drug product eligible for coverage under the School Retiree Prescription Drug Plan for each prescription drug expense shall be limited to 30 days if the prescription is filled at a retail pharmacy, and 90 days if the prescription is filled through the mail-order pharmacy. f. The amount of out-of-pocket expense that a retiree or eligible dependent shall pay in a calendar year for eligible prescription drug expenses under the School Retiree Prescription Drug Plan shall be limited in the first year of the plan to the amount in effect on July 1, 2007 for retiree prescription drug coverage under the State Health Benefits Program. The commission shall promulgate rules that shall establish a formula for a reasonable annual escalator to the amount of out-of-pocket expense. g. In the fifth year following the initial appointment of all of its members, the commission shall, as part of the fifth year audit and review undertaken pursuant to section 40 of P.L.2007, c.103 (C.52:14-17.46.10), review the amounts established in this section and make any changes that it deems appropriate pursuant to section 40 of P.L.2007, c.103 (C.52:14-17.46.10) by majority vote of the full authorized membership of the commission. L.2007, c.103, s.38. 52:14-17.46.9 Obligations of employer for charges for benefits; funds; subaccount. 39. a. For each active covered employee and for the eligible dependents the employee may have enrolled at the employee's option, from funds appropriated therefor, the employer shall pay to the commission the premium or periodic charges for the benefits provided under the contract in amounts equal to the premium or periodic charges for the benefits provided under such a contract covering the employee and the employee's enrolled dependents. b. The obligations of any employer to pay the premium or periodic charges for health benefits coverage provided under the School Employees' Health Benefits Program Act, sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11), may be determined by means of a binding collective negotiations agreement, including any agreement in force at the time the employer commences participation in the School Employees' Health Benefits Program. With respect to employees for whom there is no majority representative for collective negotiations purposes, the employer may, in its sole discretion, modify the respective payment obligations set forth in law for the employer and such employees in a manner consistent with the terms of any collective negotiations agreement binding on the employer. Commencing on the effective date of P.L.2010, c.2 and upon the expiration of any applicable binding collective negotiations agreement in force on that effective date, employees shall pay 1.5 percent of base salary, through the withholding of the contribution, for health benefits coverage provided under P.L.2007, c.103 (C.52:14-17.46.1 et seq.), notwithstanding any other amount that may be required additionally pursuant to this subsection by means of a binding collective negotiations agreement or the modification of payment obligations. c. There is hereby established a School Employee Health Benefits Program fund consisting of all contributions to premiums and periodic charges remitted to the State treasury by participating employers for employee coverage. All such contributions shall be deposited in the fund and the fund shall be used to pay the portion of the premium and periodic charges attributable to employee and dependent coverage. d. The fund shall contain a dedicated subaccount reserved for payment of claims and other health services fees for covered health services and prescription drug benefits provided to covered employees and their enrolled eligible dependents. No person shall use or authorize the use of the assets in the subaccount, or the investment earnings thereon, for any purpose other than for the provision of benefits in accordance with the terms of the School Employees' Health Benefits Program and for defraying the reasonable costs of administering the subaccount. A third-party medical claims reviewer, procured pursuant to section 2 of P.L.2019, c.143 (C.52:14-17.30b), shall, in the performance of services for the program, act in the best interests of the State, participating employers, and covered employees and their enrolled eligible dependents. Nothing in this subsection shall be construed as subjecting the program, its plans, the State, or any participating employer to the provisions of the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1001 et seq.). The third-party medical claims reviewer shall collect, store and maintain a secure archive of medical and prescription drug claims data and other health services payment information and provide such data and other reports in compliance with applicable State and federal laws, including the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191, to document the cost and nature of claims incurred, demographic information on the covered population, emerging utilization and demographic trends, and such other information as may be available to assist in the governance of the program and in timely response to any requests from the Governor, the State Treasurer, the Division of Pensions and Benefits, the School Employees' Health Benefits Commission, the School Employees' Health Benefits Plan Design Committee, the President of the Senate, and the Speaker of the General Assembly. Such claims data shall include, but not be limited to, for each claim, the claim number, provider information, amount charged, amount paid, and the Current Procedural Terminology (CPT) code. The School Employees' Health Benefits Commission, the School Employees' Health Benefits Plan Design Committee, the State Treasurer, or the Division of Pensions and Benefits may direct the third-party medical claims reviewer to provide appropriate medical and prescription drug claims and other health services payment data to a health care services provider or other authorized entity, in compliance with applicable State and federal laws, including the "Health Insurance Portability and Accountability Act of 1996," Pub.L.104-191, for the specific purpose of improving the quality and value of health care services delivered to program participants. The State Treasurer shall deposit into the subaccount the moneys necessary to accomplish the purposes of this subsection, including moneys paid by employers participating in the program, and contributed by covered employees and retirees. Deposits and contributions to the subaccount shall be applied to the distribution of payments for the costs of health care services and prescription drug benefits and to fund the reasonable costs of administering the subaccount. Assets in the subaccount shall be expended or withdrawn, and deposits and withdrawals shall be reconciled, in accordance with regulations and procedures adopted pursuant to this subsection. Moneys in the subaccount shall be invested in permitted investments or shall be held in interest-bearing accounts in such depositories as the State Treasurer may select, and may be invested and reinvested in permitted investments or invested and reinvested in the same manner as other accounts in the custody of the State Treasurer as provided by law. All interest or other income or earnings derived from the investment or reinvestment of moneys in the subaccount shall be credited thereto and shall be determined on an aggregate basis for all participating employers. The State Treasurer shall adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), such rules and regulations as may be necessary to implement the provisions of this act, P.L.2019, c.143 (C.52:14-17.30a et al.). e. Notwithstanding any law to the contrary and except as provided by amendment by P.L.2010, c.2, and by P.L.2011, c.78, the payment in full of premium or periodic charges for eligible retirees and their dependents pursuant to section 3 of P.L.1987, c.384 (C.52:14-17.32f), section 2 of P.L.1992, c.126 (C.52:14-17.32f1), or section 1 of P.L.1995, c.357 (C.52:14-17.32f2) shall be continued without alteration or interruption and there shall be no premium sharing or periodic charges for certain school employees in retirement once they have met the criteria for vesting for pension benefits, which criteria for purposes of this subsection only shall mean the criteria for vesting in the Teachers' Pension and Annuity Fund. For purposes of this subsection, "premium sharing or periodic charges" shall mean payments by eligible retirees based upon a proportion of the premiums for health care benefits. L.2007, c.103, s.39; amended 2010, c.2, s.6; 2011, c.78, s.54; 2019, c.143, s.6. 52:14-17.46.10 Annual report, audit to Governor, Legislature. 40. a. The School Employees' Health Benefits Commission shall publish annually, at least 30 days prior to the commencement of the open enrollment period for that year, a report showing the fiscal transactions of the program for the preceding calendar year and stating other facts pertinent to the program and all participating employers. b. At the same time as the annual report is published, the commission shall publish an audit report of the program's costs and the aggregate usage of plan participants during the preceding calendar year, which audit shall be prepared by a qualified independent auditor selected by the commission in accordance with applicable laws regarding selection of auditing services. The independent auditor shall include in its report specific recommendations that are projected to result in cost savings to the State and to participating employers. The specific recommendations to be submitted in the annual audit report shall include, but not be limited to, savings achievable through disease management, prescription benefit management, and elimination of administrative and program inefficiencies. In addition, the annual audit may recommend changes to the benefits provided under the School Employees' Health Benefits Program that improve the overall ability to retain and attract eligible employees. c. The commission shall submit the annual report and annual audit report to the Governor and the Legislature, and shall make these reports available to every participating employer. d. At the start of the fifth year following the initial appointment of all of its members, and at the start of every fifth year thereafter, the commission shall contract with an independent, qualified auditor, separate from the person performing the annual audit described in subsection b. of this section, for a comprehensive review and audit of all elements of the program, as well as the plan design and structure for each plan offered by the commission. The auditor shall be qualified by experience, training, resources, and education to perform intensive audits of public health insurance plans that are of a similar size and scope and shall be familiar with benefit designs of employers that are eligible but do not participate in the commission. The auditor shall be selected in accordance with applicable law. e. Each fifth year review and audit shall be the annual audit for that year and the review shall include all of the elements contained in the annual audit plus the additional reviews set forth in this subsection. In addition to performing the tasks of the annual audit, the auditor selected for a fifth year review shall review the program costs, plan design, and plan structure and may issue recommendations for cost sharing measures, including modifications of co-payments, deductibles, out-of-pocket maximums, limits, exclusions, and other measures to be considered for implementation by the commission. The commission is authorized to implement such recommendations pursuant to majority vote of the full authorized membership of the commission. The commission shall submit the five-year review and audit report to the Governor and the Legislature and shall make the report available to every participating employer. L.2007, c.103, s.40. 52:14-17.46.11 Applicability of State Health Benefits Program Act. 41. All provisions of P.L.1961, c.49 (C.52:14-17.25 et seq.) applicable to the State Health Benefits Program shall, except as expressly stated in the School Employees' Health Benefits Program Act, be construed as applicable to participating employers and to their employees and to dependents of such employees, and to retirees and to dependents of such retirees, in the School Employees' Health Benefits Program. L.2007, c.103, s.41. 52:14-17.46.12 School Employees' Health Benefits Commission to establish audit program. 2. The School Employees' Health Benefits Commission shall establish and contract for a Medicare Primary Assignment and Audit Program through which it shall conduct a continuous review of the School Employees' Health Benefits Program for the purposes of ensuring that all persons who are participants and their dependents of the School Employees' Health Benefits Program and who are eligible for Medicare under federal law are properly enrolled in Medicare with Medicare as the primary provider of their health care benefits coverage and with the School Employees' Health Benefits Program as their secondary provider of their health care benefits coverage. L.2018, c.88, s.2. 52:14-17.46.13 Health care benefit plans offered. 1. This section shall apply to the School Employees' Health Benefits Program (SEHBP) and to those employers defined pursuant to section 32 of P.L.2007, c.103 (C.52:14-17.46.2) that participate in the program. a. (1) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, beginning with the plan year that commences January 1, 2021 and for each plan year thereafter, the School Employees' Health Benefits Program shall offer only three plans that provide medical and prescription drug benefits for employees, and retirees who are not Medicare-eligible, and their dependents if any. All other plans offered prior to January 1, 2021 for employees, and retirees who are not Medicare-eligible, and their dependents if any, shall be terminated. The three plans shall be the New Jersey Educators Health Plan as developed by the School Employees' Health Benefits Plan Design Committee in accordance with subsection f. of this section which sets forth the plan design of the New Jersey Educators Health Plan; the SEHBP NJ Direct 10 plan as adopted and implemented by the School Employees' Health Benefits Commission for the plan year that began January 1, 2020; and the SEHBP NJ Direct 15 plan as adopted and implemented by the School Employees' Health Benefits Commission for the plan year that began January 1, 2020. Employers that participate in the School Employees' Health Benefits Program shall retain the ability to enter the program for medical only plans and may separately purchase pharmacy and dental benefits outside of the program without limitation or restriction. (2) Only the plans set forth in this section shall be offered by the program regardless of any collective negotiations agreement between a participating employer and its employees in effect on the effective date of this act, P.L.2020, c.44, that provides for enrollment in other plans that were offered by the program prior to January 1, 2021. b. Prior to January 1, 2021, the program, through the Division of Pensions and Benefits in the Department of the Treasury, shall provide for an enrollment period during which all employees who commenced employment prior to the effective date of this act shall be required to select affirmatively one of the three plans specified in subsection a. of this section. If an employee fails to select affirmatively a plan during this enrollment period, the program shall enroll the employee, and the employee's dependents if any, in the New Jersey Educators Health Plan for the plan year beginning January 1, 2021 and ending December 31, 2021. During the enrollment period, any person who is enrolled in a plan offered by the program and who is paying the full cost of health care benefits coverage shall also be required to select affirmatively one of the three plans specified in subsection a. of this section. If a person fails to select affirmatively a plan during this enrollment period, the program shall enroll the person, and the person's dependents if any, in the New Jersey Educators Health Plan for the plan year beginning January 1, 2021 and ending December 31, 2021. Any such person shall continue to pay the full cost of coverage and shall not be subject to the contribution schedule or any mandatory enrollment period as set forth in this section. c. (1) Beginning on January 1, 2021, an employee commencing employment on or after the effective date of this act but before January 1, 2028 who does not waive coverage shall be enrolled by the program, with the employee's dependents if any, in the New Jersey Educators Health Plan, or the Garden State Health Plan if selected by the employee. The employee shall remain enrolled in either the New Jersey Educators Health Plan or the Garden State Health Plan selected by the employee at the annual open enrollment for each plan year through the plan year that ends December 31, 2027, provided that the employee during this period may waive coverage as an employee and select and change the type of coverage received under the plan following a qualifying life event, in accordance with the program regulations. The enrollment required by this paragraph shall not include an employee who commenced employment prior to the effective date of P.L.2020, c.44 and who did not enroll, who waived enrollment, or who was not eligible to enroll prior to that effective date for health care coverage provided by the employer, including, but not limited to, an employee who commenced employment as a part-time employee prior to the effective date of P.L.2020, c.44. If such an employee was required to enroll prior to the effective date of P.L.2021, c.163 in accordance with this paragraph, the employee shall be notified promptly in writing that enrollment is not mandatory and shall be provided promptly with an opportunity to select enrollment in another health care benefits plan.For the plan year beginning January 1, 2028, the employee may select, during any open enrollment period or at such other times or under such conditions as the program may provide, any plan offered by the program. (2) For the plan year beginning January 1, 2021, the program shall enroll a retiree who is not Medicare-eligible, and the retiree's dependents if any, in the New Jersey Educators Health Plan for health care benefits coverage as a retiree, if the retiree does not waive coverage. The retiree shall remain enrolled in that plan for each plan year through the plan year that ends December 31, 2027 or until the retiree becomes eligible for Medicare, whichever comes first. The retiree who becomes eligible for Medicare shall no longer be eligible for enrollment in the New Jersey Educators Health Plan, except that any dependent of the retiree who is not eligible for Medicare may remain eligible for coverage under the New Jersey Educators Health Plan. For the plan year beginning January 1, 2028, that retiree who is not Medicare-eligible may select, during any open enrollment period or at such other times or under such conditions as the program may provide, any plan offered by the program. (3) Except as otherwise provided in this subsection or subsection b. of this section, selection of a plan shall be at the sole discretion of the employee or retiree who is not Medicare-eligible. d. Beginning January 1, 2022 and for each plan year thereafter, the program shall offer a fourth plan to be called the Garden State Health Plan. The plan shall be developed by the School Employees' Health Benefits Plan Design Committee. If the committee does not adopt a design for the Garden State Health Plan by December 31, 2020, the Division of Pensions and Benefits in the Department of the Treasury may develop the Garden State Health Plan. The program shall provide an enrollment period prior to January 1, 2022. The Garden State Health Plan shall provide medical and prescription drug benefits that are equivalent to the level of medical and prescription drug benefits provided by the New Jersey Educators Health Plan, except that the benefits under the Garden State Health Plan shall be available only from providers located in the State of New Jersey. Access to a service provider that is located outside of the State shall be available only under such terms, conditions, restrictions, and limitations as the plan design committee or the division, as appropriate, shall provide in the plan governing documents. Employers that participate in the School Employees' Health Benefits Program shall retain the ability to enter the program for medical only plans and may separately purchase pharmacy and dental benefits outside of the program without limitation or restriction. e. The plan design of the New Jersey Educators Health Plan, the Garden State Health Plan, the NJ Direct 10 plan, and the NJ Direct 15 plan as those plan designs are specified in subsections a., d., and f. of this section shall remain unchanged until December 31, 2027. No change in the plan design of those plans shall be made before that date unless such a change in plan design is required by federal or State law to governmental health care benefits plans or to both governmental and non-governmental health care benefits plans. For the plan year that commences January 1, 2028 and for each plan year thereafter, the plan design of the New Jersey Educators Health Plan, the Garden State Health Plan, the NJ Direct 10 plan, and the NJ Direct 15 plan as those plan designs are specified in subsections a., d., and f. of this section may be modified by the School Employees' Health Benefits Plan Design Committee. Modifications to plan design of the plans set forth in this section made by the School Employees' Health Benefits Plan Design Committee or the State Treasurer pursuant to section 7 of this act shall be implemented by the program for the purposes of this section commencing January 1, 2024. f. The plan design of the New Jersey Educators Health Plan shall be the following: In Network Benefits Coverage Member Coinsurance:10%, Applies Only to Emergency Transportation Care and Durable Medical Equipment Deductible:N/A Out-of-Pocket Maximum:$500 Single/ $1,000 Family (covers all in network copayments, coinsurance, and deductible) Emergency Room Copayment:$125 (To be Waived if Admitted) PCP Office Visit Copayment:$10 Specialist Office Visit Copayment$15Out-of-Network Benefits Coverage Member Coinsurance:30% of the Out-of-Network Fee Schedule Deductible:$350 / $700 Out-of-Pocket Maximum:$2,000 Single / $5,000 Family Routine Lab:Paid at Out-of-Network Benefit Level Out-of-Network Fee Schedule:200% of CMS - MedicarePharmacy Out-of-Pocket Maximum:$1,600 Single / $3,200 Family (Indexed Annually Pursuant to Federal Law)Generic Copayment:$5 Retail 30 Day Supply / $10 Mail 90 Day SupplyBrand Copayment:$10 Retail 30 Day Supply/ $20 Mail 90 Day SupplyMandatory Generic:Member Pays Difference in Cost Between Generic and Brand, Plus Brand CopaymentFormulary: Closed Formulary as contracted with the Pharmacy Benefit Manager and the School Employees' Health Benefits CommissionOther Chiropractic, Physical Therapy, and Acupuncture: Subject to the same Out-of-Network Limits as for the State Health Benefits Program as were in effect on June 1, 2020 to take effect as of July 1, 2020, or as soon thereafter as reasonably practicable. Under a patient centered medical home model, there shall be no office visit copay for primary care for participants who select and commit to a patient centered medical home for primary care in accordance with plan rules and regulations. g. Any plan offered by the School Employees' Health Benefits Program shall require that chiropractic, physical therapy, and acupuncture benefits shall be subject to the same out-of-network limits as for the State Health Benefits Program that were in effect on June 1, 2020 to take effect as of July 1, 2020 or as soon thereafter as reasonably practicable. h. Notwithstanding any provision of law, rule, or regulation to the contrary, for any period of time during which the employer does not have to pay a premium or periodic charge for any health care benefits plan or program provided to its employees through the School Employees' Health Benefits Program, an employee enrolled in such plan or program shall not be required to make the employee's contribution toward that premium or periodic charge during that period of time. In the event that a collective negotiations agreement specifically addresses a premium holiday the collective negotiations agreement shall be controlling. L.2020, c.44, s.1; amended 2021, c.163, s.2. 52:14-17.46.14 Annual contribution from employee, retiree. 2. a. Each employee, and retiree who is not Medicare-eligible and who is required by another provision of law to contribute in retirement toward the cost of health care benefits coverage under the program, shall contribute annually toward the cost of health care benefits coverage for the employee and retiree, and dependents if any, under the New Jersey Educators Health Plan offered by the School Employees' Health Benefits Program an amount equal to a percentage of the employee's annual base salary or retiree's annual retirement allowance, including any cost of living adjustments to that allowance. The contribution shall be withheld by the employer from the salary of the employee or by the retirement system from the retirement allowance, including any cost of living adjustments to that allowance, of the retiree who is not Medicare-eligible. The percent to be contributed shall be as follows with the retirement allowance including any cost of living adjustments to that allowance: For Base Salary or Retirement Allowance of $40,000 or Less: 1.7% for Single Coverage; 2.2% for Parent and Child(ren) Coverage; 2.8% for Employee and Spouse Coverage; and 3.3% for Family Coverage For Base Salary or Retirement Allowance of more than $40,000 to $50,000: 1.9% for Single Coverage; 2.5% for Parent and Child(ren) Coverage; 3.3% for Employee and Spouse Coverage; and 3.9% for Family Coverage For Base Salary or Retirement Allowance of more than $50,000 to $60,000: 2.2% for Single Coverage; 2.8% for Parent and Child(ren) Coverage; 3.9% for Employee and Spouse Coverage; and 4.4% for Family Coverage For Base Salary or Retirement Allowance of more than $60,000 to $70,000: 2.5% for Single Coverage; 3% for Parent and Child(ren) Coverage; 4.4% for Employee and Spouse Coverage; and 5% for Family Coverage For Base Salary or Retirement Allowance of more than $70,000 to $80,000: 2.8% for Single Coverage; 3.3% for Parent and Child(ren) Coverage; 5% for Employee and Spouse Coverage; and 5.5% for Family Coverage For Base Salary or Retirement Allowance of more than $80,000 to $90,000: 3% for Single Coverage; 3.6% for Parent and Child(ren) Coverage; 5.5% for Employee and Spouse Coverage; and 6% for Family Coverage For Base Salary or Retirement Allowance of more than $90,000 to $100,000: 3.3% for Single Coverage; 3.9% for Parent and Child(ren) Coverage; 6% for Employee and Spouse Coverage; and 6.6% for Family Coverage For Base Salary or Retirement Allowance of more than $100,000 to $125,000: 3.6% for Single Coverage; 4.4% for Parent and Child(ren) Coverage; 6.6% for Employee and Spouse Coverage; and 7.2% for Family Coverage When the base salary or retirement allowance is more than $125,000, the amount to be contributed shall be the same as for a base salary or retirement allowance of $125,000. b. Each employee, and retiree who is not Medicare-eligible and who is required by another provision of law to contribute in retirement toward the cost of health care benefits coverage under the program, shall contribute annually toward the cost of health care benefits coverage for the employee and retiree, and dependents if any, under the Garden State Health Plan offered by the School Employees' Health Benefits Program an amount equal to a percentage of the employee's annual salary or retiree's annual retirement allowance, including any cost of living adjustments to that allowance. The contribution shall be withheld by the employer from the salary of the employee or by the retirement system from the retirement allowance, including any cost of living adjustments to that allowance, of the retiree who is not Medicare-eligible. The percent to be contributed shall be one-half of the percentage set forth in subsection a. of this section for the salary or retirement allowance range and type of coverage, except that the contribution specified in this subsection shall not be less than the minimum annual contribution for health care benefits coverage of 1.5% of salary or retirement allowance, including any cost of living adjustments to that allowance, as required by law. c. (1) An employee enrolled in the New Jersey Educators Health Plan or the Garden State Health Plan shall be required to pay only the contribution specified in subsection a. or b. of this section, notwithstanding any other provision of law, rule, or regulation to the contrary requiring contributions by employees toward the cost of health care benefits coverage under the program, except as provided in subsection b. of this section. No other contribution may be required by collective negotiations agreement, except as set forth in subsection h. of this section. (2) Only those retirees who are not Medicare-eligible and who are required by another provision of law to contribute in retirement toward the cost of health care coverage under the program shall be required to pay the contribution specified in subsection a. or b. of this section for coverage under the New Jersey Educators Health Plan or the Garden State Health Plan. A retiree who is not Medicare-eligible, who is enrolled in the New Jersey Educators Health Plan or the Garden State Health Plan, and who is required by another provision of law to contribute in retirement toward the cost of health care coverage under the program shall be required to pay only the contribution specified in subsection a. or b. of this section, notwithstanding the provisions of section 77 of P.L.2011, c.78 (C.52:14-17.28e), section 3 of P.L.1987, c.384 (C.52:14-17.32f), section 2 of P.L.1992, c.126 (C.52:14-17.32f1), or section 1 of P.L.1995, c.357 (C.52:14-17.32f2) to the contrary requiring contributions by retirees toward the cost of health care benefits coverage under the program, except as provided in subsection b. of this section. d. Employees who are not enrolled in the New Jersey Educators Health Plan or the Garden State Health Plan shall continue, after the effective date of this act, P.L.2020, c.44, to contribute to health care benefits coverage and those contributions shall be determined in accordance with what is permitted or required by provisions of law. An employee who is enrolled in a plan other than the New Jersey Educators Health Plan or the Garden State Health Plan shall be required to contribute toward the cost of health care benefits coverage under the program (a) in accordance with a collective negotiations agreement applicable to that employee as negotiated prior to or after the effective date of this act, P.L.2020, c.44, pursuant to the requirements that were set forth in law on the day next preceding that effective date; (b) as may be required at the discretion of the employer; or (c) as required by a provision of law, whichever is applicable to that employee. With regard to contributions by an employee who is enrolled in a plan other than the New Jersey Educators Health Plan or the Garden State Health Plan, no provision in this section shall be deemed to modify, alter, impair, or terminate the requirement in sections 77 and 78 of P.L.2011, c.78 (C.18A:16-17.2 and C.52:14-17.28e), as applicable, that a public employer and employees who were in negotiations for the collective negotiations agreement to be executed after the employees in that unit had reached full implementation of the premium share set forth in section 39 of P.L.2011, c.78 (C.52:14-17.28c) shall conduct negotiations concerning contributions for health care benefits as if the full premium share was included in the prior contract. Nothing in this act shall be deemed to modify, alter, impair, or terminate the continued compliance after the effective date of this act with that requirement for negotiations for any collective negotiations agreement for employee contributions for plans other than the New Jersey Educators Health Plan or the Garden State Health Plan. e. For an employee, the annual base salary paid by the employer for the position held by the employee shall be used to identify the percentage to be used to calculate the annual contribution required under subsections a. and b. of section 2 of this act. For a retiree who is not Medicare-eligible, the annual retirement allowance, including any cost of living adjustments to that allowance, received by the retiree shall be used to identify the percentage to be used to calculate the annual contribution required under subsections a. and b. of section 2 of this act. f. The annual contribution by an employee or a retiree who is not Medicare-eligible as calculated in accordance with subsection a. or b. of this section shall not exceed the amount as calculated in accordance with section 4 of this act, P.L.2020, c.44 (C.52:14-17.46.16). g. The contributions required by this section shall apply to employees for whom the employer has assumed a health care benefits payment obligation, to require that such employees pay the amount of contribution specified in this section for health care benefits coverage. The contributions required by this section shall apply to retirees for whom the State has assumed a health care benefits payment obligation but who are required by law to contribute toward the cost of health care benefits coverage under the program, to require that such retirees pay the amount of contribution specified in this section for health care benefits coverage. h. For the plan year that commences on January 1, 2028 and for each plan year thereafter, the contributions required pursuant to subsections a. and b. of this section for employees enrolled in the New Jersey Educators Health Plan or the Garden State Health Plan may be modified through collective negotiations agreements entered into between the employers who participate in the School Employees' Health Benefits Program and their employees. The contributions required pursuant to subsections a. and b. of this section shall become part of the parties' collective negotiations and shall then be subject to collective negotiations in a manner similar to other negotiable items between the parties. Negotiations concerning contributions for health care benefits shall be conducted as if the contributions required pursuant to subsections a. and b. of this section were included in the prior contract. The contribution scheme of percentage of base salary set forth in those subsections may be modified or a new contribution scheme or method other than a percentage of salary may be provided for in accordance with a collective negotiations agreement. i. Modifications to the contribution rates set forth in this section made by the School Employees' Health Benefits Plan Design Committee or the State Treasurer pursuant to section 7 of this act shall be implemented by the program for the purposes of this section commencing January 1, 2024. L.2020, c.44, s.2; amended 2020, c.137, s.1. 52:14-17.46.15 Guidance tool. 3. a. The School Employees' Health Benefits Commission shall prepare, in coordination with the Division of Pensions and Benefits in the Department of the Treasury, a guidance tool to provide employees and retirees who are not Medicare-eligible with confidential consultations online with regard to the employee's or retiree's decision to select a plan during a period of open enrollment or at other times. The guidance tool shall operate using information supplied by the employee or retiree as answers to questions concerning the health care needs of the employee or retiree, and the employee's or retiree's dependents if any. b. A comprehensive health and wellness plan intended to provide biometric screening services, chronic condition coaching services, and smoking cessation services shall be available to all members of the School Employees' Health Benefits Program, including all members of the New Jersey Educators Health Plan and the Garden State Health Plan. The School Employees' Health Benefits Commission shall provide, through a contract, for the services of wellness related providers for employees and retirees, and their dependents if any, enrolled in the program. The contract awarded by the commission shall be offered to employers, as defined in section 32 of P.L.2007, c.103 (C.52:14-17.46.2), who do not participate in the program so that their employees may have access to the same services and under same terms, conditions, and costs as the employees of employers who do participate. The School Employees' Health Benefits Program shall promote, on an on-going basis, the expansion of the use of patient centered medical homes. The School Employees' Health Benefits Plan Design Committee shall seek also to adopt, on an on-going basis, efforts and measures to support expanded population health arrangements that manage costs and prevent inappropriate utilization. c. All provisions of law regarding the School Employees' Health Benefits Program shall remain applicable to the extent not inconsistent with, and shall not be interpreted in a manner that creates a direct impediment to the implementation of, this section and sections 1, 2, and 4 of this act, P.L.2020, c.44 (C.52:14-17.46.13, C.52:14-17.46.14, and C.52:14-17.46.16). L.2020, c.44, s.3. 52:14-17.46.16 Calculation of contribution. 4. For employees and retirees who are not Medicare-eligible who are required to make a contribution pursuant to subsection a. or b. of section 2, or subsection d. of section 5, of this act, P.L.2020, c.44 (C.18A:16-13.2), due to enrollment in the New Jersey Educators Health Plan or the Garden State Health Plan, or the equivalent plan, as appropriate, a calculation shall be made in accordance with this section. The employee or retiree shall be required to contribute the lesser of: the amount calculated for that employee or retiree in accordance with subsection a. or b. of section 2, or in accordance with subsection d. of section 5, of this act, as appropriate; or the amount calculated for that employee or retiree in accordance with this section. for family coverage or its equivalent - an employee or retiree who earns less than $25,000 shall pay 3 percent of the cost of coverage; an employee or retiree who earns $25,000 or more but less than $30,000 shall pay 4 percent of the cost of coverage; an employee or retiree who earns $30,000 or more but less than $35,000 shall pay 5 percent of the cost of coverage; an employee or retiree who earns $35,000 or more but less than $40,000 shall pay 6 percent of the cost of coverage; an employee or retiree who earns $40,000 or more but less than $45,000 shall pay 7 percent of the cost of coverage; an employee or retiree who earns $45,000 or more but less than $50,000 shall pay 9 percent of the cost of coverage; an employee or retiree who earns $50,000 or more but less than $55,000 shall pay 12 percent of the cost of coverage; an employee or retiree who earns $55,000 or more but less than $60,000 shall pay 14 percent of the cost of coverage; an employee or retiree who earns $60,000 or more but less than $65,000 shall pay 17 percent of the cost of coverage; an employee or retiree who earns $65,000 or more but less than $70,000 shall pay 19 percent of the cost of coverage; an employee or retiree who earns $70,000 or more but less than $75,000 shall pay 22 percent of the cost of coverage; an employee or retiree who earns $75,000 or more but less than $80,000 shall pay 23 percent of the cost of coverage; an employee or retiree who earns $80,000 or more but less than $85,000 shall pay 24 percent of the cost of coverage; an employee or retiree who earns $85,000 or more but less than $90,000 shall pay 26 percent of the cost of coverage; an employee or retiree who earns $90,000 or more but less than $95,000 shall pay 28 percent of the cost of coverage; an employee or retiree who earns $95,000 or more but less than $100,000 shall pay 29 percent of the cost of coverage; an employee or retiree who earns $100,000 or more but less than $110,000 shall pay 32 percent of the cost of coverage; an employee or retiree who earns $110,000 or more shall pay 35 percent of the cost of coverage for individual coverage or its equivalent - an employee or retiree who earns less than $20,000 shall pay 4.5 percent of the cost of coverage; an employee or retiree who earns $20,000 or more but less than $25,000 shall pay 5.5 percent of the cost of coverage; an employee or retiree who earns $25,000 or more but less than $30,000 shall pay 7.5 percent of the cost of coverage; an employee or retiree who earns $30,000 or more but less than $35,000 shall pay 10 percent of the cost of coverage; an employee or retiree who earns $35,000 or more but less than $40,000 shall pay 11 percent of the cost of coverage; an employee or retiree who earns $40,000 or more but less than $45,000 shall pay 12 percent of the cost of coverage; an employee or retiree who earns $45,000 or more but less than $50,000 shall pay 14 percent of the cost of coverage; an employee or retiree who earns $50,000 or more but less than $55,000 shall pay 20 percent of the cost of coverage; an employee or retiree who earns $55,000 or more but less than $60,000 shall pay 23 percent of the cost of coverage; an employee or retiree who earns $60,000 or more but less than $65,000 shall pay 27 percent of the cost of coverage; an employee or retiree who earns $65,000 or more but less than $70,000 shall pay 29 percent of the cost of coverage; an employee or retiree who earns $70,000 or more but less than $75,000 shall pay 32 percent of the cost of coverage; an employee or retiree who earns $75,000 or more but less than $80,000 shall pay 33 percent of the cost of coverage; an employee or retiree who earns $80,000 or more but less than $95,000 shall pay 34 percent of the cost of coverage; an employee or retiree who earns $95,000 or more shall pay 35 percent of the cost of coverage; for member with child or spouse coverage or its equivalent - an employee or retiree who earns less than $25,000 shall pay 3.5 percent of the cost of coverage; an employee or retiree who earns $25,000 or more but less than $30,000 shall pay 4.5 percent of the cost of coverage; an employee or retiree who earns $30,000 or more but less than $35,000 shall pay 6 percent of the cost of coverage; an employee or retiree who earns $35,000 or more but less than $40,000 shall pay 7 percent of the cost of coverage; an employee or retiree who earns $40,000 or more but less than $45,000 shall pay 8 percent of the cost of coverage; an employee or retiree who earns $45,000 or more but less than $50,000 shall pay 10 percent of the cost of coverage; an employee or retiree who earns $50,000 or more but less than $55,000 shall pay 15 percent of the cost of coverage; an employee or retiree who earns $55,000 or more but less than $60,000 shall pay 17 percent of the cost of coverage; an employee or retiree who earns $60,000 or more but less than $65,000 shall pay 21 percent of the cost of coverage; an employee or retiree who earns $65,000 or more but less than $70,000 shall pay 23 percent of the cost of coverage; an employee or retiree who earns $70,000 or more but less than $75,000 shall pay 26 percent of the cost of coverage; an employee or retiree who earns $75,000 or more but less than $80,000 shall pay 27 percent of the cost of coverage; an employee or retiree who earns $80,000 or more but less than $85,000 shall pay 28 percent of the cost of coverage; an employee or retiree who earns $85,000 or more but less than $100,000 shall pay 30 percent of the cost of coverage. an employee or retiree who earns $100,000 or more shall pay 35 percent of the cost of coverage. The annual base salary of an employee shall be used to determine what the employee earns for the purpose of determining the percent of the cost of coverage. The annual retirement allowance, including any cost of living adjustments to that allowance, of a retiree who is not Medicare-eligible shall be used to determine what the retiree earns for the purpose of determining the percent of the cost of coverage. As used in this section, "cost of coverage" means the premium or periodic charges for medical and prescription drug plan coverage, but not for dental, vision, or other health care, provided: (1) under the New Jersey Educators Health Plan or the Garden State Health Plan offered by the School Employees' Health Benefits Program pursuant to section 1 of P.L.2020, c.44 (C.52:14-17.46.13); or (2) under the equivalent New Jersey Educators Health Plan or the equivalent Garden State Health Plan offered by an employer pursuant to section 5 of P.L.2020, c.44 (C.18A:16-13.2) when that employer is not a participant in the School Employees' Health Benefits Program. L.2020, c.44, s.4.

This is the verbatim text of N.J.S.A. 52:14-17.45, 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.