N.J. Stat. § 26:2J-1 Short title
This act may be cited as the "Health Maintenance Organizations Act." L.1973, c. 337, s. 1, eff. Dec. 27, 1973.
N.J. Stat. tit. 26, ch. 2J
N.J. Stat. tit. 26, ch. 2J
in effectN.J. Stat. § 26:2J-2 Definitions
a. "Commissioner" means the State Commissioner of Health. b. "Basic health care services" means those services, including but not limited to emergency care, inpatient hospital and physician care, and outpatient medical services, designated by regulations promulgated by the commissioner. c. "Health care services" includes basic health care services and any additional services designated by regulations promulgated by the commissioner. d. "Enrollee" means an individual who has been enrolled with a health maintenance organization. e. "Evidence of coverage" means any booklet, certificate, agreement, or contract issued to an enrollee setting out the services and other benefits to which he is entitled. f. "Health maintenance organization" means any person which directly or through contracts with providers furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographical area. g. "Person" means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, or corporations. h. "Provider" means any physician, hospital, or other person which is licensed or otherwise authorized in this State to furnish health care services. i. "Health care facility" means the facility or institution whether public or private, engaged in providing services for health maintenance organizations, diagnosis or treatment of human disease, pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, mental hospital, public health center, diagnostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, tuberculosis hospital, chronic disease hospital, maternity hospital, outpatient clinic, dispensary, home health care agency, boarding home or other home for the sheltered care of adult persons and bio-analytical laboratory or central services facility serving one or more such institutions but excluding institutions that provide healing solely by prayer. L.1973, c. 337, s. 2, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-3 Establishment of health maintenance organizations
a. Notwithstanding any law of this State to the contrary, any person may apply to the commissioner for and obtain a certificate of authority to establish and operate a health maintenance organization in compliance with this act. No person shall establish or operate a health maintenance organization in this State without compliance with regulations to be promulgated by the commissioner, nor sell, offer to sell, or solicit offers to purchase or receive advance or periodic consideration in conjunction with a health maintenance organization without obtaining a certificate of authority under this act. When the establishment or operation of a health maintenance organization involves the construction of a health care facility or any change in or expansion of a health care facility or involves the institution of new health care services as defined in section 7 of the Health Care Facilities Planning Act (P.L.1971, c. 136, C. 26:2H-7), said health maintenance organization shall abide by all provisions of P.L.1971, c. 136. All health care facilities utilized by a health maintenance organization or its agents shall comply with the licensure provisions of section 12 of the Health Care Facilities Planning Act (C. 26:2H-12). b. Every health maintenance organization as of the effective date of this act shall submit an application for a certificate of authority under subsection c. of this section within 90 days of the effective date of this act. Each such applicant may continue to operate until the commissioner acts upon the application. In the event that an application is denied under section 4, hereof, the applicant shall henceforth be treated as a health maintenance organization whose certificate of authority has been revoked. c. Each application for a certificate of authority shall be verified by an officer or authorized representative of the applicant, shall be in a form prescribed by the commissioner, and shall set forth or be accompanied by the following: (1) a copy of the basic organizational document of the applicant such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable documents, and all amendments thereto; (2) a copy of the bylaws, rules and regulations, or similar document regulating the conduct of the internal affairs of the applicant; (3) a list of the names, addresses, and official positions of the persons who are to be responsible for the conduct of the affairs of the applicant; (4) a copy of any contract made or to be made between any providers or persons listed in paragraph (3) of this subsection and the applicant; (5) a copy of any contract made or to be made with an insurer or a hospital or medical service corporation; (6) a statement generally describing the health maintenance organization, its facilities, and personnel; (7) a copy of the form of evidence of coverage to be issued to the enrollees; (8) a copy of the form of the group contract, if any, which is to be issued to employers, unions, trustees, or other organizations; (9) recent financial statements showing the applicant's assets, liabilities, and sources of financial support; (10) a general description of the proposed method of marketing and financing and a statement as to the sources of funding; (11) a power of attorney duly executed by such applicant, if not domiciled in this State, appointing the commissioner and his successors in office, and duly authorized deputies, as the true and lawful attorney of such applicant in and for this State upon whom all lawful process in any legal action or proceeding against the health maintenance organization on a cause of action arising, in this State may be served; (12) a statement reasonably describing the geographic area or areas to be served; (13) a general description of the complaint procedures to be utilized as required under section 12, hereof; (14) a general description of the procedures and programs to be implemented to meet the quality of health care requirements in section 4 a. (2), hereof; (15) a general description of the mechanism by which enrollees will be afforded an opportunity to participate in matters of policy and operation under section 6 b., hereof; (16) such other information as the commissioner may require to make the determinations required by section 4 hereof. d. (1) a health maintenance organization shall, unless otherwise provided for in this act, file a notice describing any modification of the information required by subsection c. of this section. Such notice shall be filed with the commissioner prior to the modification. If the commissioner does not disapprove within 30 days of filing, such modification shall be deemed approved. (2) the commissioner may promulgate rules and regulations exempting from the filing requirements of paragraph (1) of this subsection those items he deems unnecessary. L.1973, c. 337, s. 3, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-4 Issuance of certificate of authority
a. (1) Upon receipt of an application for issuance of a certificate of authority the commissioner shall forthwith transmit copies of such application and accompanying documents to the Commissioner of Insurance. The approval of the Commissioner of Insurance shall be required to the extent that the proposal involves the doing of an insurance business or a contract with an insurer or hospital or medical service corporation. (2) The commissioner shall determine whether the applicant for a certificate of authority: (a) has demonstrated the potential ability to assure that such health care services will be provided in a manner to assure both availability and accessibility of adequate personnel and facilities and in a manner enhancing availability, accessibility and continuity of service; (b) has arrangements for an on-going quality of health care assurance program; and (c) has a procedure to establish and maintain a uniform system of cost accounting approved by the commissioner; establish and maintain a uniform system of reports and audits meeting the requirements of the commissioner; and prepare and review annually a long range plan for the provision of health care services, which plan shall be compatible with the State Health Plan established pursuant to the "Comprehensive Health Planning and Public Health Services Amendments of 1966" (Federal Law 89-749) as related to medical health services, health care services and health manpower. (3) Where the application has been rejected the commissioner shall specify in what respect it fails to comply and, if applicable, specifies in what respect the proposal fails to comply with the requirements of the Commissioner of Insurance. b. Issuance of a certificate of authority shall be granted upon payment of the application fee prescribed in section 23 hereof if the commissioner and, if applicable, the Commissioner of Insurance, are satisfied that the following conditions are met: (1) the health maintenance organization's proposed plan of operation meets the requirements of subsection a. (2) of this section; (2) the applicant's proposal sets forth an appropriate mechanism whereby the health maintenance organization will effectively provide or arrange for the provision of health care services on a prepaid basis; (3) the health maintenance organization is financially sound and may reasonably be expected to meet its obligations to enrollees and prospective enrollees. In making this determination, the commissioner may consider: (a) the adequacy of working capital and funding sources; (b) agreements if any, with an insurer, a hospital or medical service corporation, a government, or any other organization for insuring the payment of the cost of health care services or the provision for automatic applicability of an alternative coverage in the event of discontinuance of the plan; (c) any agreement with providers for the provision of health care services; (d) any deposit of cash or form of guaranty or security submitted in accordance with section 14 hereof to assure that the obligations will be duly performed; and (e) The financial soundness of the health maintenance organization's arrangements for health care services and the schedule of charges used in connection therewith; (4) the enrollees will be afforded an opportunity to participate in matters of policy and operation pursuant to section 6 hereof; (5) nothing in the proposed method of operation, as shown by the information submitted pursuant to section 3 hereof or by independent investigation, is contrary to the public interest; and (6) any deficiencies found by the commissioner or the Commissioner of Insurance have been corrected. c. A certificate of authority shall be denied only after compliance with the requirements of section 22 hereof. L.1973, c. 337, s. 4, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-4.1 Health maintenance organization to pay benefits for treatment of Wilm's tumor
Notwithstanding any provision of law to the contrary, every health maintenance organization for which a certificate of authority to establish and operate a health maintenance organization in this State has been issued or continued shall provide health care services to any enrollee for the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These health care services shall be provided to the same extent as for any other sickness. L.1990,c.71,s.6.
N.J. Stat. § 26:2J-4.4 Health maintenance organization, mammogram examination benefits.
6. a. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for the conduct of: (1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and (2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the health maintenance organization of the medical necessity of the additional screening and diagnostic testing. b. These health care services shall be provided to the same extent as for any other sickness under the enrollee agreement. c. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.1991, c.279, s.6; amended 1999, c.341, s.6; 2004, c.86, s.6; 2012, c.17, s.263; 2013, c.196, s.8.
N.J. Stat. § 26:2J-4.5 Health maintenance organization, benefits for "off-label" drugs required
7. a. Notwithstanding any provision of law to the contrary, and except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et al.) or P.L.1992, c.162 (C.17B:27A-17 et seq.), a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization which provides health care services for prescribed drugs approved by the federal Food and Drug Administration unless the health maintenance organization provides health care services to any enrollee for a drug prescribed for a treatment for which it has not been approved by the Food and Drug Administration if it is recognized to be medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia: (1) the American Medical Association Drug Evaluations; (2) the American Hospital Formulary Service Drug Information; (3) the United States Pharmacopoeia Drug Information; or, it is recommended by a clinical study or review article in a major-peer reviewed professional journal. b. Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment for which the drug has been prescribed. Health care services provided pursuant to this section shall be determined and provided to the same extent as other services under the enrollee plan for drugs prescribed for treatments which have been approved by the Food and Drug Administration. c. This section shall apply to health maintenance organization plans in which the right to change the enrollee charge has been reserved. d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug. L.1993,c.321,s.7.
N.J. Stat. § 26:2J-4.6 Health maintenance organization, benefits for health promotion.
8. a. Notwithstanding any provision of this act or any other law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee which include a health promotion program providing health wellness examinations and counseling, which program shall include, but not be limited to, the following tests and services: (1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level, and blood high-density lipoprotein (HDL) level; (2) For all persons 35 years of age or older, a glaucoma eye test every five years; (3) For all persons 40 years of age or older, an annual stool examination for presence of blood; (4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years; (5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 5 of P.L.1995, c.415 (C.26:2J-4.12); (6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 6 of P.L.1991, c.279 (C.26:2J-4.4); (7) For all adults, recommended immunizations; and (8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination, and seat belt usage in motor vehicles. Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for an enrollee to receive a different schedule of tests and services than that provided for under this subsection, the health maintenance organization shall provide coverage for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section. b. A health maintenance organization shall not be required to offer services to enrollees set forth in subsection a. of this section for which the value exceeds: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the value of a left-sided colon examination shall not be included in the above amount; however, no health maintenance organization shall be required to provide services to enrollees for a left-sided colon examination with a value in excess of $150. c. The Commissioner of Health, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which it is reported. d. Nothing in this act shall be construed to require that a health maintenance organization take any actions which conflict with the health benefits, underwriting and rating standards established by the federal government pursuant to subchapter XI of Pub.L.93-222 (42 U.S.C. s.300e et seq.). e. This section shall apply to all health maintenance organization contracts in which the right to change the enrollee charge has been reserved. f. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.). L.1993, c.327, s.8; amended 1999, c.339, s.6; 2012, c.17, s.264.
N.J. Stat. § 26:2J-4.7 Requirements for health maintenance organization providing benefits for pharmacy services.
6. a. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization which provides pharmacy services, prescription drugs, or a prescription drug plan, unless the coverage for health care services: (1) Permits the enrollee, at the time of enrollment, to select benefit coverage allowing the enrollee to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the enrollee is registered pursuant to R.S.45:14-1 et seq.; (2) Provides that no pharmacy or pharmacist shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the health maintenance organization provides for coverage by contracted or preferred providers for pharmaceutical services, provided the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the health maintenance organization; (3) Provides that no copayment, fee, or other condition shall be imposed upon an enrollee selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all enrollees selecting a participating or contracting pharmacist or pharmacy; (4) (a) Provides that no enrollee shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy; (b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and (c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days except for any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the "Children's Health Care Coverage Program" established pursuant to P.L.1997, c.272 (C.30:4I-1 et seq.); (5) Sets forth the auditing procedures to be used by the health maintenance organization and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor, unless authorized by the Division of Medical Assistance and Health Services in the Department of Human Services with regard to any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program and "Children's Health Care Coverage Program". No audit by a health maintenance organization shall include a review of any document relating to any person or prescription plan other than those reimbursable by the health maintenance organization, unless authorized by the Division of Medical Assistance and Health Services in the Department of Human Services with regard to any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program and "Children's Health Care Coverage Program"; (6) Provides that the health maintenance organization, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the enrollee for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or the Division of Medical Assistance and Health Services in the Department of Human Services or State or federal law; (7) The provisions of P.L.1999, c.395 shall apply to all health maintenance organization contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395. b. Nothing in this section shall be construed to operate to add any coverage for health care services, to increase the scope of any coverage for health care services, or to increase the level of any health care services provided by a health maintenance organization. c. This section shall apply to health maintenance organization plans in which the right to change the enrollee charge has been reserved. L.1993,c.378,s.6; amended 1999, c.395, s.6.
N.J. Stat. § 26:2J-4.8 Benefits for certain cancer treatments
6. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no certificate of authority to establish and operate a health maintenance organization in this State shall be issued or continued on or after the effective date of this act unless the health maintenance organization offers to provide health care services to any contract holder for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. This treatment shall be provided to the same extent as for any other illness. The offer required pursuant to this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. Nothing in this section shall be construed to limit a health maintenance organization in adjusting the schedule of charges for enrollee coverage, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section. L.1995,c.100,s.6.
N.J. Stat. § 26:2J-4.9 Coverage for birth and natal care; HMO
8. a. Every enrollee agreement that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide health care services for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. b. Notwithstanding the provisions of subsection a. of this section, an enrollee agreement that provides health care services for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. c. Every health maintenance organization shall provide notice to enrollees regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the enrollee; (2) the yearly informational packet sent to the enrollee; or (3) January 1, 1996. L.1995,c.138,s.8.
N.J. Stat. § 26:2J-4.10 Health maintenance organization, child screening, blood lead, hearing loss; immunizations.
4. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) unless the health maintenance organization offers health care services to any enrollee which include: a. Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children. b. All childhood immunizations as recommended by the Department of Health, which shall consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians. A health maintenance organization shall notify its enrollees, in writing, of any change in the health care services provided with respect to childhood immunizations and any related changes in premium. The notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance. c. Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility. The health care services provided pursuant to this section shall be provided to the same extent as for any other medical condition under the contract, except that a deductible shall not be applied for services provided pursuant to this section; however, with respect to a contract that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), a deductible shall not be applied for any services provided pursuant to this section that represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 12 of P.L.2005, c.248 (C.26:2J-4.29). This section shall apply to all contracts under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.1995, c.316, s.4; 2001, c.373, s.13; 2005, c.248, s.10; 2012, c.17, s.265; 2025, c.283, s.16.
N.J. Stat. § 26:2J-4.11 Coverage, diabetes treatment by HMO contracts.
6. a. Every contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide health care services to any enrollee or other person covered thereunder for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply. The provisions of this subsection shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this subsection shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this subsection shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. b. Each contract shall also provide health care services for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of their diabetic condition, including information on proper diet. Health care services provided for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes; upon diagnosis by a participating physician or participating nurse practitioner/clinical nurse specialist of a significant change in the enrollee's or other covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a participating physician or participating nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Diabetes self-management education shall be provided by a participating dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or, pursuant to section 6 of P.L.1993, c.378 (C.26:2J-4.7), a registered pharmacist in the State qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the State of New Jersey. c. The health care services required by this section shall be provided to the same extent as for any other sickness under the contract. d. This section shall apply to all contracts in which the health maintenance organization has reserved the right to change the schedule of charges. e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.). f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional diabetes equipment and related supplies that are medically necessary for the treatment of diabetes and for which benefits shall be provided according to the provisions of this section. L.1995, c.331, s.6; amended 2023, c.105, s.16.
N.J. Stat. § 26:2J-4.12 HMO contracts, Pap smear benefits.
5. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization offers health care services to any enrollee or other person covered thereunder which include a Pap smear. The health care services shall be provided to the same extent as for any other medical condition under the contract. As used in this section, and notwithstanding the provisions of this section to the contrary, "Pap smear" means an initial Pap smear and any confirmatory test when medically necessary and as ordered by the covered person's physician and includes all laboratory costs associated with the initial Pap smear and any confirmatory test. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.1995, c.415, s.5; amended 2001, c.227, s.5; 2012, c.17, s.266.
N.J. Stat. § 26:2J-4.13 HMO certificate of authority, prostate cancer testing
5. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee which include an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors. The health care services shall be provided to the same extent as for any other medical condition under the contract. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.1996,c.125,s.5.
N.J. Stat. § 26:2J-4.14 HMO to provide benefits for reconstructive breast surgery.
6. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.1997, c.75 unless the health maintenance organization provides health care services to any enrollee, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and prostheses and, under any contract for health care services providing outpatient x-ray or radiation therapy, outpatient chemotherapy following surgical procedures in connection with the treatment of breast cancer shall be included as a part of the outpatient x-ray or radiation therapy. The health care services shall be provided to the same extent as for any other medical condition under the contract for health care services. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.1997, c.75, s.6; amended 2012, c.17, s.267.
N.J. Stat. § 26:2J-4.15 Coverage for minimum inpatient care following mastectomy by HMO.
8. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide health care services for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The enrollee agreement shall not require a health care provider to obtain authorization from the health maintenance organization for prescribing 72 or 48 hours, as appropriate, of inpatient care as provided for in this section. The provisions of this section shall not be construed to: require a patient to receive inpatient care for 72 or 48 hours, as appropriate, if the patient in consultation with the patient's physician determines that a shorter length of stay is medically appropriate; or relieve a patient or a patient's physician, if appropriate, of any notification requirements to the health maintenance organization under the enrollee agreement. The health care services shall be provided to the same extent as for any other sickness under the enrollee agreement. The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section. L.1997, c.149, s.8; amended 2012, c.17, s.268.
N.J. Stat. § 26:2J-4.16 Applicability of Health Care Quality Act
28. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act unless the health maintenance organization meets the requirements of P.L.1997, c.192 (C.26:2S-1 et al.) and regulations adopted thereto. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.1997,c.192,s.28.
N.J. Stat. § 26:2J-4.17 Coverage for treatment of inherited metabolic diseases by health maintenance organization.
8. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to each enrollee for the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the enrollee's physician. For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician. The health care services shall be provided to the same extent as for any other medical condition under the contract. The provisions of this section shall apply to all contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.1997, c.338, s.8; amended 2012, c.17, s.269.
N.J. Stat. § 26:2J-4.18 Coverage for treatment of domestic violence injuries by health maintenance organization.
6. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), no health maintenance organization shall deny health care services for the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to its enrollees. Services shall be provided to the same extent as for any other treatment. The provisions of this section shall apply to all certificates of authority in which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.1998,c.97,s.6.
N.J. Stat. § 26:2J-4.19 Coverage for certain dental procedures for the severely disabled or child age five or under by HMO.
6. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act unless the health maintenance organization provides health care services to an enrollee who is severely disabled or a child age five or under for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the enrollee agreement which requires hospitalization or general anesthesia for dental services rendered by a participating dentist regardless of where the dental services are provided. b. A health maintenance organization may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions. c. This section shall apply to all contracts for health care services in which the health maintenance organization has reserved the right to change the schedule of charges. L.1999, c.49, s.6; amended 2012, c.17, s.270.
N.J. Stat. § 26:2J-4.20 HMO to provide coverage for mental health conditions, substance use disorders; collaborative care model.
8. a. (1) Every enrollee agreement delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide health care services for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the agreement and shall meet the requirements of the federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147 and 45 C.F.R. s.156.115(a)(3). Coverage provided pursuant to this section shall include benefits delivered through the psychiatric Collaborative Care Model. (2) As used in this section: "Mental health condition" means a condition defined to be consistent with generally recognized independent standards of current medical practice referenced in the current version of the Diagnostic and Statistical Manual of Mental Disorders. "Psychiatric Collaborative Care Model" means the evidence-based, integrated behavioral health service delivery method wherein a primary care provider and a care manager collaborate with a psychiatric consultant to provide care to a patient. "Psychiatric Collaborative Care Model" shall include those benefits that are billed using the following list of Current Procedural Terminology (CPT) codes, which list shall be updated by the Commissioner of Banking and Insurance whenever the codes are altered or supplemented: (a) 99492 - Initial psychiatric collaborative care management; (b) 99493 - Subsequent psychiatric collaborative care management; and (c) 99494 - Initial or subsequent psychiatric collaborative care management, additional time. "Same terms and conditions" means that the health maintenance organization cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or health care services limits to mental health condition and substance use disorder services than those applied to substantially all other medical or surgical health care services. "Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders. b. (Deleted by amendment, P.L.2019, c.58) c. The provisions of this section shall apply to enrollee agreements in which the health maintenance organization has reserved the right to change the premium. d. Nothing in this section shall reduce the requirement for a health maintenance organization to provide benefits pursuant to section 8 of P.L.2017, c.28 (C.26:2J-4.39). L.1999, c.106, s.8; amended 2012, c.17, s.271; 2019, c.58, s.8; 2022, c.33, s.8.
N.J. Stat. § 26:2J-4.21 HMO to provide continuing nursing home care, certain.
1. a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization offers health care services in conformance with the provisions of subsection b. of this section. b. If an enrollee is a resident of a skilled nursing facility, continuing care retirement community, or a retirement community which operates a skilled nursing facility on the premises of the community, regardless of whether the health maintenance organization is under contract with the skilled nursing facility or the skilled nursing facility at the continuing care retirement community or retirement community, the enrollee's primary care physician shall refer the enrollee to the skilled nursing facility or the community's Medicare-certified skilled nursing unit, as applicable, rather than to a skilled nursing facility separate from the facility or the community of origin, if: (1) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility has the capacity to provide the services the enrollee needs; (2) the primary care physician, in consultation with the enrollee or a representative of the enrollee's family, determines that the referral is in the best interest of the enrollee; (3) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility agrees to be reimbursed at the same contract rate negotiated by the health maintenance organization with similar providers for the same services and supplies in the same geographic area; and (4) the skilled nursing facility or the continuing care retirement community or retirement community with a skilled nursing facility meets all applicable State licensing and certification requirements. c. For the purposes of this act, "continuing care retirement community" means a continuing care facility operating under a certificate of authority issued by the Department of Community Affairs pursuant to P.L.1986, c.103 (C.52:27D-330 et seq.), and "retirement community" means a retirement community which is registered with the Department of Community Affairs pursuant to P.L.1977, c.419 (C.45:22A-21 et seq.). L.1999, c.332, s.1; amended 2012, c.17, s.272.
N.J. Stat. § 26:2J-4.22 Coverage for hemophilia services by HMO
10. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the health maintenance organization meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.2000,c.121,s.10.
N.J. Stat. § 26:2J-4.23 Health maintenance organization to provide coverage for treatment of infertility.
5. a. No certificate of authority to establish and operate a health maintenance organization in this State shall be issued or continued on or after the effective date of this act unless the health maintenance organization provides health care services, to groups of more than 50 enrollees, for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. A health maintenance organization shall provide enrollee 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. A health maintenance organization 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 if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed. b. A religious employer may request, and a health maintenance organization shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3). c. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. d. The provisions of this section shall not apply to a contract for health care services by a health maintenance organization which, pursuant to a contract between the health maintenance organization and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services. e. Nothing in this section shall preclude the health maintenance organization from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines. L.2001, c.236, s.5; amended 2017, c.48, s.5; 2023, c.258, s.5.
N.J. Stat. § 26:2J-4.24 HMO agreement to provide coverage for colorectal cancer screening.
8. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide health care services to any enrollee or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person. b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force. c. The health care services shall be provided to the same extent as for any other medical condition under the enrollee agreement. d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.2001, c.295, s.8; amended 2012, c.17, s.273; 2023, c.8, s.8.
N.J. Stat. § 26:2J-4.25 Health maintenance organization prescription drug plans to cover certain infant formulas.
6. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization that provides health care services for prescription drugs under a contract, unless the health maintenance organization also provides health care services in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula. The health care services shall be provided to the same extent as for any other prescribed items under the contract. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.2001,c.361,s.6.
N.J. Stat. § 26:2J-4.26 HMO required to cover certain out-of-network services.
10. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act unless the health maintenance organization meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.2001,c.367,s.10.
N.J. Stat. § 26:2J-4.27 HMO to offer coverage for domestic partner.
52. Every health maintenance organization contract that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to an enrollee for an enrollee's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3). The provisions of this section shall apply to contracts in which the health maintenance organization has reserved the right to change the schedule of charges. L.2003,c.246,s.52.
N.J. Stat. § 26:2J-4.28 HMO, high deductible, coverage for preventive care.
11. A certificate of authority to establish and operate a health maintenance organization, which organization offers a contract that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the health maintenance organization offers health care services to any enrollee which include services provided in-network which represent medically necessary preventive care as permitted by that federal law. The services provided pursuant to this section shall be provided to the same extent as for any other medical condition under the contract, except that a deductible shall not be applied for services provided pursuant to this section. This section shall apply to all contracts under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.2005, c.248, s.11; amended 2012, c.17, s.274.
N.J. Stat. § 26:2J-4.29 Health service corporation, coverage for prescription female contraceptives.
12. Notwithstanding the provisions of section 4 of P.L.1995, c.316 (C.26:2J-4.10) regarding deductibles for a high deductible health plan, a contract offered by a health maintenance organization, which certificate of authority to establish and operate is issued or continued by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not apply a deductible for any benefits in which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.). This section shall apply to all contracts under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.2005, c.248, s.12; amended 2012, c.17, s.275.
N.J. Stat. § 26:2J-4.30 Health maintenance organization, coverage for contraceptives.
6. a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization, unless the health maintenance organization provides health care services for prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis: (1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions: (a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product. (b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. (c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration. (2) Voluntary male and female sterilization. (3) Patient education and counseling on contraception. (4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to: (a) Management of side effects; (b) Counseling for continued adherence to a prescribed regimen; (c) Device insertion and removal; (d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and (e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section. b. The coverage provided shall include prescriptions for dispensing contraceptives for: (1) (Deleted by amendment, P.L.2021, c.376) (2) up to a 12-month period at one time. c. (1) Except as provided in paragraph (2) of this subsection, the health care services shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed. (2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). d. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13. L.2005, c.251, s.6; amended 2017, c.241, s.6; 2019, c.361, s.6; 2021, c.376, s.6.
N.J. Stat. § 26:2J-4.31 HMOs to provide benefits for orthotic and prosthetic appliances.
8. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.) unless the health maintenance organization provides health care services for any person covered thereunder for expenses incurred in obtaining: (1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and (2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports. As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18). b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), a health maintenance organization shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule. c. The benefits shall be provided to the same extent as for any other medical condition under the enrollee agreement. d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.2007, c.345, s.8; amended 2012, c.17, s.276; 2025, c.89, s.8.
N.J. Stat. § 26:2J-4.32 Health maintenance organization to provide coverage for hearing aids, cochlear implant for enrollee.
9. a. A health maintenance organization contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for an enrollee, as provided in this section. b. The health care services shall include the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. A health maintenance organization may limit the health care services provided in this section to one hearing aid for each hearing-impaired ear every 24 months. c. A health maintenance organization contract shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors. d. The health care services shall be provided to the same extent as for any other condition under the contract. e. This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved. L.2008, c.126, s.9; amended 2023, c.275, s.8.
N.J. Stat. § 26:2J-4.33 Health maintenance organization to provide installment payments to obstetrical provider for maternity services.
8. a. Every certificate of authority to establish and operate a health maintenance organization issued or continued in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance, on or after the effective date of this act, for a health maintenance organization which provides benefits for maternity services, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy. b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means: (1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or (2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife. c. This section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. L.2009, c.113, s.8.
N.J. Stat. § 26:2J-4.34 Health maintenance organization to provide benefits for treatment of autism or other developmental disability.
8. Notwithstanding any other provision of law to the contrary, a health maintenance organization enrollee agreement that provides health care services and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section. a. The health maintenance organization shall provide coverage for health care services for screening and diagnosing autism or another developmental disability. b. When the enrollee's primary diagnosis is autism or another developmental disability, the health maintenance organization shall provide coverage for medically necessary occupational therapy, physical therapy, and speech therapy services, 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 enrollee is under 21 years of age and the enrollee's primary diagnosis is autism, the health maintenance organization shall provide coverage 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 coverage 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 an enrollee may make to a provider of behavioral interventions. (2) The coverage provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative. (3) (a) The maximum coverage amount for an enrollee in any calendar year through 2011 shall be $36,000. (b) Commencing on January 1, 2012, the maximum coverage 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 coverage amount shall apply to a contract that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated. (d) Notwithstanding the provisions of this paragraph to the contrary, a health maintenance organization shall not be precluded from providing a coverage amount for an enrollee in any calendar year that exceeds the coverage 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 health maintenance organization to appropriately provide coverage for health care services, 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 health maintenance organization may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the health maintenance organization 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 coverage for health care services otherwise available to an enrollee. 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 health maintenance organization of the continued medical necessity of the specified therapies and interventions. h. The provisions of this section shall apply to those enrollee agreements in which the health maintenance organization has reserved the right to change the premium. L.2009, c.115, s.8.
N.J. Stat. § 26:2J-4.35 HMO to provide coverage for oral anticancer medications.
8. a. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the contract provides for covered intravenously administered or injected anticancer medications. b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications. c. A health maintenance organization contract shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the contract as of the effective date of this act. d. This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved. L.2011, c.188, s.8.
N.J. Stat. § 26:2J-4.36 HMO to provide coverage for sickle cell anemia.
6. Every health maintenance organization contract that provides health care services and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services to an enrollee for the medical treatment of sickle cell anemia and, if the contract provides health care services for outpatient prescription drugs, then the contract shall provide health care services to an enrollee for prescription drugs for the treatment of sickle cell anemia. The health care services shall be provided to the same extent as for any other medical condition under the contract. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.2011, c.210, s.6.
N.J. Stat. § 26:2J-4.37 Health maintenance organization to provide coverage for prescription eye drops.
8. a. A health maintenance organization contract which provides hospital or medical expense benefits that include coverage for prescription eye drops, issued or continued in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that: (1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and (2) the refill requested by the enrollee or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner. b. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges. L.2013, c.50, s.8.
N.J. Stat. § 26:2J-4.38 Health maintenance organization, coverage for synchronization of prescribed medications.
6. a. Every certificate of authority to establish and operate a health maintenance organization in this State issued, continued or renewed in this State, or approved for issuance, continuation or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person: (1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications; (2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and (3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed. b. This section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form. L.2015, c.206, s.6.
N.J. Stat. § 26:2J-4.39 Health maintenance organization contract to provide benefits for substance use disorder.
8. a. A health maintenance organization contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide 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 health maintenance organization of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, a health maintenance organization 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. No health maintenance organization shall initiate concurrent review more frequently than at two-week intervals. If a health maintenance organization determines that continued inpatient care in a facility is no longer medically necessary, the health maintenance organization shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The health maintenance organization shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the health maintenance organization's determination is upheld and it is determined continued inpatient care is not medically necessary, the carrier shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider. f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services. g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the health maintenance organization and may be subject to prior authorization or, retrospective review and other utilization management requirements. h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health. i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection. k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the contract. l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section. m. The provisions of this section shall apply to those contracts in which the health maintenance organization has reserved the right to change the premium. n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.). o. The provisions of this section shall not apply to a health maintenance organization contract which, pursuant to a contract between the health maintenance organization and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services. p. As used in this section: "Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans. "Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal. L.2017, c.28, s.8.
N.J. Stat. § 26:2J-4.40 Health maintenance organization to provide coverage regardless of gender identity, expression.
8. a. Notwithstanding any other law or regulation to the contrary, a health maintenance organization contract that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the health maintenance organization shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person. b. The discrimination prohibited by this section shall include: (1) denying, cancelling, limiting or refusing to issue or renew a contract on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or (4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person: (a) health care services related to gender transition if coverage is available for those services under the contract when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or (b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition. c. For the purposes of this section: "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth. "Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth. "Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity. "Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth. d. The provisions of this section shall apply to those contracts for health care services under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. e. Nothing in this section shall preclude the health maintenance organization from performing utilization review, including periodic review of the medical necessity of a particular service. L.2017, c.176, s.8.
N.J. Stat. § 26:2J-4.41 HMO to cover digital tomosynthesis of the breast.
8. a. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age. b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the contract shall be applied. c. This section shall apply to those contracts for health care services under which the health maintenance organization has reserved the right to change the schedule of charges for enrollee coverage. L.2017, c.305, s.8.
N.J. Stat. § 26:2J-4.42 HMO to provide coverage for donated human breast milk.
8. a. A health maintenance organization contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in the provision of pasteurized donated human breast milk, which may include human milk fortifiers if indicated by the prescribing licensed medical practitioner, provided that: (1) the covered person is an infant under the age of six months; (2) the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health; and (3) a licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or (4) a licensed medical practitioner has issued an order for an infant who meets any of the following conditions: (a) a body weight below healthy levels determined by the licensed medical practitioner; (b) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or (c) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health. b. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the health maintenance organization has reserved the right to change the schedule of charges. c. Nothing in this section shall preclude the health maintenance organization from performing utilization review, including periodic review of the medical necessity of a particular service. d. The benefits shall be provided to the same extent as for any other prescribed items under the contract. e. If there is no supply of human breast milk that meets the requirements of paragraph (2) of subsection a. of this section, the health maintenance organization shall not be required to provide coverage of expenses pursuant to this section. L.2017, c.309, s.8.
N.J. Stat. § 26:2J-4.43 Health maintenance organization to provide coverage for standard fertility preservation services.
5. a. A health maintenance organization contract that provides hospital or medical expense benefits for groups with more than 50 persons and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. For the purposes of this section: "Iatrogenic infertility" means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. "May directly or indirectly cause" means a medical treatment with a likely side effect of iatrogenic infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes. The benefits shall be provided to the same extent as for any other medical condition under the contract. The same copayments, deductibles, and benefit limits shall apply to the provision of standard fertility preservation services pursuant to this section as those applied to other medical or surgical benefits under the contract. b. A health maintenance organization providing coverage under this section shall not determine the provision of standard fertility preservation services based on an enrollee's expected length of life, present or predicted disability, degree of medical dependency, perceived quality of life, or other health conditions, or based on personal characteristics, including age, sex, sexual orientation, marital status, or gender identity. c. This section shall apply to those health maintenance organization contracts in which the health maintenance organization has reserved the right to change the premium. L.2019, c.306, s.5.
N.J. Stat. § 26:2J-4.44 Health maintenance organization to provide coverage for breastfeeding support.
8. a. A health maintenance organization contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for 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 health maintenance organization may determine whether a rental or purchase is covered. (c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump. (d) A health maintenance organization may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump. (3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. (4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the health maintenance organization cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the contract shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts. (5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the health maintenance organization shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment. c. Coverage of comprehensive lactation counseling and lactation consultation shall include: (1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions: (a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits. (b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need. (2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need. (3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups. (4) A contract shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) A health maintenance organization shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, a health maintenance organization shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided. e. As used in this section: "Cost-sharing" means deductible, co-insurance or co-payments, or similar charges. "Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump. "Lactation consultant" means an individual who is an International Board Certified Lactation Consultant. "Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services. Lactation care and services shall include, but not be limited to: (1) lactation assessment through the systematic collection of subjective and objective data; (2) analysis of data and creation of a plan of care; (3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider; (4) evaluation of outcomes; (5) provision of lactation education to parents and health care providers; and (6) the recommendation and use of assistive devices. "Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as: (1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding; (2) acting as an advocate for breastfeeding as the norm for feeding infants and young children; (3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals; (4) using principles of adult education when teaching clients, health care providers, and others in the community; and (5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately. "Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is: (1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or (2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication. f. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. L.2019, c.343, s.8.
N.J. Stat. § 26:2J-4.45 Health maintenance organization to cover preventive services.
8. a. A health maintenance organization contract that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services: (1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the Department of Health, which shall in making its recommendations consider the recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the federal Department of Health and Human Services and, as appropriate, the recommendations of the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Physicians; (3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration; and (4) with respect to women, any additional preventive care and screenings not described in paragraph (1) as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. b. (1) Except as provided in paragraph (2) of this subsection, nothing in this section shall: (a) require a contract which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or (b) preclude a contract which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider. (2) If a contract does not have in its network a provider who can provide an item or service described in subsection a. of this section, the contract shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service. c. (1) A contract shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued. (2) (a) Except as provided in subparagraph (b) of this paragraph, a contract that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year. (b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section. d. The provisions of this section shall apply to those contracts in which the health maintenance organization has reserved the right to change the premium. e. With respect to an annual wellness visit for a covered member who is over three years of age, a carrier is required to cover only one wellness visit per plan year or calendar year, as provided for under the health benefits plan contract, but may not impose a waiting period for the wellness visit. L.2019, c.360, s.8; amended 2025, c.283, s.17; 2025, c.386, s.8.
N.J. Stat. § 26:2J-4.46 Health maintenance organization to provide certain coverage for prescription drugs.
8. a. Notwithstanding any other provision of law to the contrary, a health maintenance organization that offers a contract that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, shall ensure that at least 25 percent of all plans, or at least one plan if the organization offers less than four plans, offered by the organization in each rating area and in each of the bronze, silver, gold, and platinum levels of coverage, in the individual market pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), and in the small employer market pursuant to P.L.1992, c.162 (C.17B:27A-17), shall conform with the following: (1) (a) an agreement that provides a silver, gold, or platinum level of coverage, as defined in 45 C.F.R. s.156.140, shall limit a covered person's cost-sharing, including any copayment or coinsurance, for prescription drugs, including specialty drugs, to no more than $150 per month for each prescription drug for up to a 30-day supply of any single drug; (b) an agreement that provides a bronze level of coverage, as defined in 45 C.F.R. s.156.140, shall ensure that any required covered person's cost-sharing, including any copayment or coinsurance, does not exceed $250 per month for each prescription drug for up to a 30-day supply of any single drug; (c) an agreement that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall be exempt from the requirements of subparagraphs (a) and (b) of this paragraph; (2) except as provided in paragraph (3) of this subsection, the limits described in paragraph (1) of this subsection shall apply at any point in the benefit design, including before and after any applicable deductible is reached; and (3) for prescription drug benefits offered in conjunction with a high-deductible health plan, the plan shall not provide prescription drug benefits until the expenditures applicable to the deductible under the plan have met the amount of the minimum annual deductibles in effect for self-only and family coverage under section 223(c)(2)(A)(i) of the federal Internal Revenue Code (26 U.S.C. s.223(c)(2)(A)(i)) for self-only and family coverage, respectively. Once the foregoing expenditure amount has been met under the plan, coverage for prescription drug benefits shall begin, and the limit on out-of-pocket expenditures for prescription drug benefits shall be as specified in paragraph (1) of this subsection. b. The provisions of this section shall apply to all agreements in which the health maintenance organization has reserved the right to change the premium. L.2019, c.471, s.8.
N.J. Stat. § 26:2J-4.47 Health maintenance organization to cover adolescent depression screenings.
8. A health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service. The health care services shall be provided to the same extent as for any other condition under the contract, except that the health maintenance organization shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance. This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved. L.2021, c.73, s.8.
N.J. Stat. § 26:2J-4.48 HMO to cover newborn home nurse visitation.
12. a. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The benefits shall: (1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159); (2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant; (3) ensure that the plan does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and (4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing: (a) a value-based payment methodology; (b) an invoice claim process; (c) a capitated payment arrangement; (d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or (e) any other payment arrangement agreed to by the carrier and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required pursuant to the health benefits plan for such services shall be waived. c. Every health maintenance organization that is subject to the provisions of this section shall submit to the Department of Banking and Insurance, in a form and manner prescribed by the department, a report on the claims submitted for services provided under the newborn home nurse visitation program. The information contained in the report shall be shared with the Department of Children and Families and used by that department to assess the newborn home nurse visitation program pursuant to subsection a. of section 4 of P.L.2021, c.187 (C.26:2H-161). d. (1) Except as provided in paragraphs (2) and (3) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section. (2) A contract offered by a health maintenance organization that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). (3) A contract offered by a health maintenance organization that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law. e. The benefits shall be provided to the same extent as for any other medical condition under the contract. L.2021, c.187, s.12.
N.J. Stat. § 26:2J-4.49 Contract, health care services, coverage, epinephrine auto-injector device.
17. A contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent a health maintenance organization from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.17.
N.J. Stat. § 26:2J-4.50 Contract, health care services, coverage, prescription asthma inhaler.
18. A contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide benefits to an enrollee or other person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent a health maintenance organization from reducing an enrollee's or other covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.18.
N.J. Stat. § 26:2J-4.51 Biomarker precision medical testing coverage, health maintenance organization contracts.
8. a. Each health maintenance organization contract for health care services that is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services for biomarker precision medical testing, as defined by subsection g. of this section. b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of an enrollee when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an enrollee's disease or condition is recognized by: (1) labeled indications for an FDA-approved or -cleared test; (2) indicated tests for an FDA-approved drug; (3) actions to address warnings and precautions on FDA-approved drug labels; (4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or (5) nationally recognized clinical practice guidelines. c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of an enrollee. d. (1) If utilization review is required, a health maintenance organization shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The enrollee and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the enrollee shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. e. The health care services shall be provided to the same extent as for any other medical condition under the contract, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions. f. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved. g. As used in this section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression. "Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care. L.2025, c.49, s.8.
N.J. Stat. § 26:2J-4.52 Certificate of authority to establish and operate a health maintenance organization, HIV preexposure prophylaxis, HIV postexposure prophylaxis.
10. a. (1) Except as provided in paragraph (2) of this subsection, notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Banking and Insurance on or after the effective date of this act unless the health maintenance organization provides health care services to any enrollee for expenses incurred for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy. (2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the plan to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy. b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the health maintenance organization to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria: (1) the service or procedure is within the scope of practice of the treating pharmacist; and (2) the service or procedure would otherwise be covered by the health maintenance organization if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant. c. A health maintenance organization shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the health maintenance organization to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service. d.A health maintenance organization shall not: (1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and (2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period. e. Nothing in this section shall be construed to require a health maintenance organization to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit. f. The benefits shall be provided to the same extent as for any other medical condition under the contract. g. As used in this section: “HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). “HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). “Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits. L.2025, c.196, s.10.
N.J. Stat. § 26:2J-4.53 Benefits provided under enrollee agreements.
6. a. Every enrollee agreement that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any enrollee or other person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of 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. A health maintenance organization shall provide clear and accessible information to enrollees regarding covered perimenopause and menopause treatments. c. The benefits shall be provided to the same extent as for any other medical condition under the enrollee agreement. d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges. e. As used in this section: “Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period. “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles. L.2025, c.200, s.6.
N.J. Stat. § 26:2J-5 Powers of health maintenance organizations
a. The powers of a health maintenance organization include the following: (1) the purchase, lease, construction, renovation, operation, or maintenance of health care facilities, and their ancillary equipment, and such property as may reasonably be required for its principal office or for such other purposes as may be necessary in the transaction of the business of the organization; (2) the receiving of funds by loan or otherwise; (3) the making of loans to a medical group under contract with it in furtherance of its program or the making of loans to a corporation or corporations under its control for the purpose of acquiring or constructing health care facilities or in furtherance of a program providing health care services to enrollees; (4) the assumption of responsibility for the furnishing of health care services through providers which are under contract with or employed by the health maintenance organization to persons including but not limited to enrollees; (5) the contracting with any person for the performance on its behalf of certain functions such as marketing, enrollment and administration; (6) the contracting with an insurance company licensed in this State, or with a hospital or medical service corporation authorized to do business in this State, for the provision of insurance, indemnity, or reimbursement against the cost of health care services provided by the health maintenance organization which may include provisions for reasonable classifications for the purpose of establishing rates and reasonable restrictions based on underwriting consideration; and (7) the offering, in addition to basic health care services, of: (a) additional health care services; (b) indemnity benefits covering out-of-area or emergency services; and (c) indemnity benefits, in addition to those relating to out-of-area and emergency services, provided through insurers or hospital or medical service corporations. b. (1) A health maintenance organization shall file notice, with adequate supporting information, with the commissioner prior to the exercise of any power granted in subsection a. (1) or (2) of this section. The commissioner shall disapprove such exercise of power if in his opinion it would substantially and adversely affect the financial soundness of the health maintenance organization and endanger its ability to meet its obligations. If the commissioner does not disapprove within 30 days of filing, it shall be deemed approved. (2) The commissioner may promulgate rules and regulations exempting from the filing requirements of paragraph (1) of this subsection those activities having a de minimis effect. L.1973, c. 337, s. 5, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-6 Governing body
a. The governing body of any health maintenance organization may include providers, other individuals, or both. b. Such governing body shall establish a mechanism to afford the enrollees an opportunity to participate in matters of policy and operation through the establishment of advisory panels, by the use of advisory referenda on major policy decisions, or through the use of other mechanisms. L.1973, c. 337, s. 6, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-7 Protection against wrongful acts
Any director, officer employee or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of such organization shall be bonded in an amount to be determined by the commissioner. L.1973, c. 337, s. 7, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-8 Evidence of coverage
8. Evidence of coverage. a. (1) Enrollees are entitled to receive evidence of coverage and evidence of the total amount of payment which the enrollee is obligated to prepay for health care services and, where applicable, for indemnity benefits. If an enrollee obtains coverage through an insurance policy or through a contract issued by a hospital or medical service corporation or health service corporation, whether by option or otherwise, the insurer or the hospital or medical service corporation or health service corporation shall issue the evidence of coverage. Otherwise, the health maintenance organization shall issue the evidence of coverage. (2) No evidence of coverage, or amendment thereto, shall be issued or delivered to any person until a copy of the form of the evidence of coverage, or amendment thereto, has been filed with the commissioner or, where applicable, with the Commissioner of Insurance. (3) An evidence of coverage shall contain: (a) provisions or statements which are not unjust, unfair, inequitable, misleading, deceptive, or which encourage misrepresentation, or which are untrue, misleading or deceptive as defined in subsection a. of section 15 of P.L.1973, c.337 (C.26:2J-15); and (b) a clear and complete statement, if a contract, or a reasonably complete summary, if a certificate, of: (i) the health care services and where applicable the insurance or other benefits, if any, to which enrollees are entitled; (ii) any limitations on the services, kind of services, benefits, or kind of benefits, to be provided, including any deductible or co-payment feature; (iii) where and in what manner information is available as to how services may be obtained; (iv) a clear and understandable description of the health maintenance organization's method for resolving enrollee complaints; and (v) the total amount of payment for health care services and the indemnity or service benefits, if any, which the enrollee is obligated to pay with respect to individual contracts, or an indication whether the plan is contributory or non-contributory with respect to group certificates. (4) Any subsequent change may be evidenced in a separate document issued to the enrollee. b. (1) no schedule of charges for enrollee coverage for health care services, or amendment thereto, may be used by a health maintenance organization until a copy of such schedule, or amendment thereto, has been filed with the Commissioner of Insurance for informational purposes; provided, however, that the Commissioner of Insurance may bring an enforcement action pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) if the commissioner has reason to believe that the rates are excessive, inadequate or unfairly discriminatory. (2) such charges may be established in accordance with actuarial principles for various categories of enrollees, provided that charges applicable to an enrollee shall not be individually determined based on the status of his health. However, the charges shall not be excessive, inadequate, or unfairly discriminatory. A certification, by a qualified actuary, to the appropriateness of the charges, based on reasonable assumptions, shall accompany the filing. c. In accordance with the provisions of section 26 of P.L.1995, c.73 (C.26:2J-44), the commissioner or, where applicable, the Commissioner of Insurance shall approve any form if the requirements of subsection a. of this section are met. It shall be unlawful to issue such form until approved. A form that is disapproved may be resubmitted for approval in accordance with subsections b., c., and d. of section 25 of P.L.1995, c.73 (C.26:2J-43) and shall be subject to review in accordance with the procedure described in the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder. Any such form which is filed by the commissioner or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith. d. The commissioner or Commissioner of Insurance, where applicable, may require the submission of whatever relevant information he deems necessary in determining whether to approve or disapprove a filing made pursuant to subsection a. of this section. L.1973,c.337,s.8; amended 1994,c.11,s.11; 1995,73,s.28.
N.J. Stat. § 26:2J-8.1 Health maintenance organization to receive, transmit transactions electronically; standards.
7. a. Within 180 days of the adoption of a timetable for implementation pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health maintenance organization or its agent or a subsidiary that processes health care benefits claims as a third party administrator, shall demonstrate to the satisfaction of the Commissioner of Banking and Insurance that it will adopt and implement all of the standards to receive and transmit health care transactions electronically, according to the corresponding timetable, and otherwise comply with the provisions of this section, as a condition of its continued authorization to do business in this State. The Commissioner of Banking and Insurance may grant extensions or waivers of the implementation requirement when it has been demonstrated to the commissioner's satisfaction that compliance with the timetable for implementation will result in an undue hardship to a health maintenance organization, or its agent, its subsidiary or its covered persons. b. Within 12 months of the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health maintenance organization or its agent or a subsidiary that processes health care benefits claims as a third party administrator shall use the standard health care enrollment and claim forms in connection with all group and individual health maintenance organization coverage for health care services issued, delivered, executed or renewed in this State. c. Twelve months after the adoption of regulations establishing standard health care enrollment and claim forms by the Commissioner of Banking and Insurance pursuant to section 1 of P.L.1999, c.154 (C.17B:30-23), a health maintenance organization or its agent shall require that health care providers file all claims for payment for health care services. A covered person who receives health care services shall not be required to submit a claim for payment, but notwithstanding the provisions of this subsection to the contrary, a covered person shall be permitted to submit a claim on his own behalf, at the covered person's option. All claims shall be filed using the standard health care claim form applicable to the contract. d. For the purposes of this subsection, "substantiating documentation" means any information specific to the particular health care service provided to a covered person. (1) Effective 180 days after the effective date of P.L.1999, c.154, a health maintenance organization or its agent, hereinafter the payer, shall remit payment for every insured claim submitted by a covered person or health care provider, no later than the 30th calendar day following receipt of the claim by the payer or no later than the time limit established for the payment of claims in the Medicare program pursuant to 42 U.S.C. s.1395u(c)(2)(B), whichever is earlier, if the claim is submitted by electronic means, and no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means, if: (a) the health care provider is eligible at the date of service; (b) the person who received the health care service was covered on the date of service; (c) the claim is for a service or supply covered under the health benefits plan; (d) the claim is submitted with all the information requested by the payer on the claim form or in other instructions that were distributed in advance to the health care provider or covered person in accordance with the provisions of section 5 of P.L.2023, c.296 (C.17B:30-55.4); and (e) the payer has no reason to believe that the claim has been submitted fraudulently. (2) If all or a portion of the claim is not paid within the time frames provided in paragraph (1) of this subsection because: (a) the claim submission is incomplete because the required substantiating documentation has not been submitted to the payer; (b) the diagnosis coding, procedure coding, or any other required information to be submitted with the claim is incorrect; (c) the payer disputes the amount claimed; or (d) there is strong evidence of fraud by the provider and the payer has initiated an investigation into the suspected fraud, the payer shall notify the health care provider, by electronic means and the covered person in writing within 30 days of receiving an electronic claim, or notify the covered person and health care provider in writing within 40 days of receiving a claim submitted by other than electronic means, that: (i) the claim is incomplete with a statement as to what substantiating documentation is required for adjudication of the claim; (ii) the claim contains incorrect information with a statement as to what information must be corrected for adjudication of the claim; (iii) the payer disputes the amount claimed in whole or in part with a statement as to the basis of that dispute; or (iv) the payer finds there is strong evidence of fraud and has initiated an investigation into the suspected fraud in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (3) If all or a portion of an electronically submitted claim cannot be adjudicated because the diagnosis coding, procedure coding or any other data required to be submitted with the claim was missing, the payer shall electronically notify the health care provider or its agent within seven days of that determination and request any information required to complete adjudication of the claim. (4) Any portion of a claim that meets the criteria established in paragraph (1) of this subsection shall be paid by the payer in accordance with the time limit established in paragraph (1) of this subsection. (5) A payer shall acknowledge receipt of a claim submitted by electronic means from a health care provider, no later than two working days following receipt of the transmission of the claim. (6) If a payer subject to the provisions of P.L.1983, c.320 (C.17:33A-1 et seq.) has reason to believe that a claim has been submitted fraudulently, it shall investigate the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), or refer the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (7) Payment of an eligible claim pursuant to paragraphs (1) and (4) of this subsection shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means and on or before the 40th calendar day following receipt of a claim submitted by other than electronic means. If payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of paragraph (2) or paragraph (3) of this subsection, the claims payment shall be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, for claims submitted by electronic means and the 40th calendar day for claims submitted by other than electronic means, following receipt by the payer of the required documentation or information or modification of an initial submission. If payment is withheld on all or a portion of a claim by a payer pursuant to paragraph (2) or (3) of this subsection and the provider is not notified within the time frames provided for in those paragraphs, the claim shall be deemed to be overdue. (8) (a) No payer that has reserved the right to change the premium shall deny payment on all or a portion of a claim because the payer requests documentation or information that is not specific to the health care service provided to the covered person. (b) No payer shall deny payment on all or a portion of a claim while seeking coordination of benefits information unless good cause exists for the payer to believe that other insurance is available to the covered person. Good cause shall exist only if the payer's records indicate that other coverage exists. Routine requests to determine whether coordination of benefits exists shall not be considered good cause. (c) In the event payment is withheld on all or a portion of a claim by a payer pursuant to subparagraph (a) or (b) of this paragraph, the claims payment shall be deemed to be overdue if not remitted to the claimant or his agent by the payer on or before the 30th calendar day or the time limit established by the Medicare program, whichever is earlier, following receipt by the payer of a claim submitted by electronic means or on or before the 40th calendar day following receipt of a claim submitted by other than electronic means. (9) An overdue payment shall bear simple interest at the rate of 12% per annum. The interest shall be paid to the health care provider at the time the overdue payment is made. The amount of interest paid to a health care provider for an overdue claim shall be credited to any civil penalty for late payment of the claim levied by the Department of Human Services against a payer that does not reserve the right to change the premium. (10) With the exception of claims that were submitted fraudulently or submitted by health care providers that have a pattern of inappropriate billing or claims that were subject to coordination of benefits, no payer shall seek reimbursement for overpayment of a claim previously paid pursuant to this section later than 18 months after the date the first payment on the claim was made. No payer shall seek more than one reimbursement for overpayment of a particular claim. At the time the reimbursement request is submitted to the health care provider, the payer shall provide written documentation that identifies the error made by the payer in the processing or payment of the claim that justifies the reimbursement request. No payer shall base a reimbursement request for a particular claim on extrapolation of other claims, except under the following circumstances: (a) in judicial or quasi-judicial proceedings, including arbitration; (b) in administrative proceedings; (c) in which relevant records required to be maintained by the health care provider have been improperly altered or reconstructed, or a material number of the relevant records are otherwise unavailable; or (d) in which there is clear evidence of fraud by the health care provider and the payer has investigated the claim in accordance with its fraud prevention plan established pursuant to section 1 of P.L.1993, c.362 (C.17:33A-15), and referred the claim, together with supporting documentation, to the Office of the Insurance Fraud Prosecutor in the Department of Law and Public Safety established pursuant to section 32 of P.L.1998, c.21 (C.17:33A-16). (11) (a) In seeking reimbursement for the overpayment from the health care provider, except as provided for in subparagraph (b) of this paragraph, no payer shall collect or attempt to collect: (i) the funds for the reimbursement on or before the 45th calendar day following the submission of the reimbursement request to the health care provider; (ii) the funds for the reimbursement if the health care provider disputes the request and initiates an appeal on or before the 45th calendar day following the submission of the reimbursement request to the health care provider and until the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section are exhausted; or (iii) a monetary penalty against the reimbursement request, including but not limited to, an interest charge or a late fee. The payer may collect the funds for the reimbursement request by assessing them against payment of any future claims submitted by the health care provider after the 45th calendar day following the submission of the reimbursement request to the health care provider or after the health care provider's rights to appeal set forth under paragraphs (1) and (2) of subsection e. of this section have been exhausted if the payer submits an explanation in writing to the provider in sufficient detail so that the provider can reconcile each covered person's bill. (b) If a payer has determined that the overpayment to the health care provider is a result of fraud committed by the health care provider and the payer has conducted its investigation and reported the fraud to the Office of the Insurance Fraud Prosecutor as required by law, the payer may collect an overpayment by assessing it against payment of any future claim submitted by the health care provider. (12) No health care provider shall seek reimbursement from a payer or covered person for underpayment of a claim submitted pursuant to this section later than 18 months from the date the first payment on the claim was made, except if the claim is the subject of an appeal submitted pursuant to subsection e. of this section or the claim is subject to continual claims submission. No health care provider shall seek more than one reimbursement for underpayment of a particular claim. e. (1) A health maintenance organization or its agent, hereinafter the payer, shall establish an internal appeal mechanism to resolve any dispute raised by a health care provider regardless of whether the health care provider is under contract with the payer regarding compliance with the requirements of this section or compliance with the requirements of sections 5 through 15 of P.L.2023, c.296 (C.17B:30-55.4 through 17B:30-55.14). No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of an appeal pursuant to this subsection. The payer shall conduct the appeal at no cost to the health care provider. A health care provider may initiate an appeal on or before the 90th calendar day following receipt by the health care provider of the payer's claims determination, which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance which shall describe the type of substantiating documentation that must be submitted with the form. The payer shall conduct a review of the appeal and notify the health care provider of its determination on or before the 30th calendar day following the receipt of the appeal form. If the health care provider is not notified of the payer's determination of the appeal within 30 days, the health care provider may refer the dispute to arbitration as provided by paragraph (2) of this subsection. If the payer issues a determination in favor of the health care provider, the payer shall comply with the provisions of this section and pay the amount of money in dispute, if applicable, with accrued interest at the rate of 12% per annum, on or before the 30th calendar day following the notification of the payer's determination on the appeal. Interest shall begin to accrue on the day the appeal was received by the payer. If the payer issues a determination against the health care provider, the payer shall notify the health care provider of its findings on or before the 30th calendar day following the receipt of the appeal form and shall include in the notification written instructions for referring the dispute to arbitration as provided by paragraph (2) of this subsection. The payer shall report annually to the Commissioner of Banking and Insurance the number of appeals it has received and the resolution of each appeal. (2) Any dispute regarding the determination of an internal appeal conducted pursuant to paragraph (1) of this subsection may be referred to arbitration as provided in this paragraph. The Commissioner of Banking and Insurance shall contract with a nationally recognized, independent organization that specializes in arbitration to conduct the arbitration proceedings. Any party may initiate an arbitration proceeding on or before the 90th calendar day following the receipt of the determination which is the basis of the appeal, on a form prescribed by the Commissioner of Banking and Insurance. No dispute shall be accepted for arbitration unless the payment amount in dispute is $1,000 or more, except that a health care provider may aggregate his own disputed claim amounts for the purposes of meeting the threshold requirements of this subsection. No dispute pertaining to medical necessity which is eligible to be submitted to the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11) shall be the subject of arbitration pursuant to this subsection. (3) The arbitrator shall conduct the arbitration proceedings pursuant to the rules of the arbitration entity, including rules of discovery subject to confidentiality requirements established by State or federal law. (4) An arbitrator's determination shall be: (a) signed by the arbitrator; (b) issued in writing, in a form prescribed by the Commissioner of Banking and Insurance, including a statement of the issues in dispute and the findings and conclusions on which the determination is based; and (c) issued on or before the 30th calendar day following the receipt of the required documentation. The arbitration shall be nonappealable and binding on all parties to the dispute. (5) If the arbitrator determines that a payer has withheld or denied payment in violation of the provisions of this section, the arbitrator shall order the payer to make payment of the claim, together with accrued interest, on or before the 10th business day following the issuance of the determination. If the arbitrator determines that a payer has withheld or denied payment on the basis of information submitted by the health care provider and the payer requested, but did not receive, this information from the health care provider when the claim was initially processed pursuant to subsection d. of this section or reviewed under internal appeal pursuant to paragraph (1) of this subsection, the payer shall not be required to pay any accrued interest. (6) If the arbitrator determines that a health care provider has engaged in a pattern and practice of improper billing and a refund is due to the payer, the arbitrator may award the payer a refund, including interest accrued at the rate of 12% per annum. Interest shall begin to accrue on the day the appeal was received by the payer for resolution through the internal appeals process established pursuant to paragraph (1) of this subsection. (7) The arbitrator shall file a copy of each determination with and in the form prescribed by the Commissioner of Banking and Insurance. f. As used in this section, "insured claim" or "claim" means a claim by a covered person for payment of benefits under an insured health maintenance organization contract for which the financial obligation for the payment of a claim under the health maintenance organization coverage for health care services rests upon the health maintenance organization. g. Any person found in violation of this section with a pattern and practice as determined by the Commissioner of Banking and Insurance shall be liable to a civil penalty as set forth in section 17 of P.L.2005, c.352 (C.17B:30-55). L.1999,c.154,s.7; amended 2005, c.352, s.15; 2023, c.296, s.24.
N.J. Stat. § 26:2J-9 Annual report
a. Every health maintenance organization shall annually, on or before March 1, file a report verified by at least two principal officers with the commissioner, with a copy to the Commissioner of Insurance covering the preceding calendar year. b. Such report shall be on forms prescribed by the commissioner and shall include: (1) a financial statement of the organization, including its balance sheet and receipts and disbursements for the preceding year certified by an independent public accountant; (2) any material changes in the information submitted pursuant to section 3 c. hereof; (3) the number of persons enrolled during the year, the number of enrollees as of the end of the year and the number of enrollments terminated during the year; (4) a summary of information compiled pursuant to section 4 a. (2)(c) hereof in such form as required by the commissioner"; and (5) such other information relating to the performance of the health maintenance organization as is necessary to enable the commissioner to carry out his duties under this act. L.1973, c. 337, s. 9, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-10 Information to enrollees
a. Every health maintenance organization shall annually provide to its enrollees: (1) a summary of any material changes since the issuance of the last report; (2) a description of the available health care services and information as to where and how to secure them; and (3) a clear and understandable description of the health maintenance organization's method for resolving enrollee complaints. b. Every health maintenance organization shall make available to its enrollees the most recent annual statement of financial condition. L.1973, c. 337, s. 10, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-10.1 Coverage provided by health maintenance organization for subscriber's child.
13. a. A health maintenance organization contract or certificate in which dependent coverage is available shall continue to make that coverage available for an adult child until the child turns 26 years of age. A contract or certificate shall not deny coverage for an enrollee's child for health care services on the grounds that: (1) The child was born out of wedlock; (2) The child is not claimed as a dependent on the enrollee's federal tax return; (3) The child does not reside with the enrollee or in the health maintenance organization's service area, provided that the child complies with the terms and conditions of the coverage with respect to the use of specified providers; (4) The child is married; (5) The child has or adopts a child; or (6) The child starts or leaves school. b. If a child has coverage through a health maintenance organization plan of a noncustodial parent, the health maintenance organization shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain health care services through the child's noncustodial parent's coverage; (2) Permit the custodial parent, or the health care provider with the authorization of the custodial parent, to submit claims for health care services without the approval of the noncustodial parent; and (3) Make payments on claims submitted in accordance with paragraph (2) of this subsection directly to the custodial parent, the health care provider or the Division of Medical Assistance and Health Services in the Department of Human Services which administers the State Medicaid program, as appropriate. c. When a parent who is the enrollee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the health maintenance organization shall: (1) Permit the parent to enroll his child as a dependent, without regard to any open enrollment restrictions; (2) Permit the child's other parent, or the Division of Medical Assistance and Health Services as the State Medicaid agency or the Division of Family Development as the State IV-D agency, in the Department of Human Services, to enroll the child if the parent who is the enrollee fails to enroll the child; and (3) Not terminate coverage of the child unless the parent who is the enrollee provides the health maintenance organization with satisfactory written evidence that: the court or administrative order is no longer in effect; or the child is or will be enrolled in a comparable health benefits plan whose coverage will be effective on the date of the termination of coverage. L.1995, c.288, s.13; amended 2019, c.356, s.8.
N.J. Stat. § 26:2J-10.2 Requirements applicable to State Medicaid
14. A health maintenance organization shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, that are different from requirements applicable to an agent or assignee of any other enrollee. L.1995,c.288,s.14.
N.J. Stat. § 26:2J-10.3 Coverage for certain dependents until age 31 by health maintenance organization.
6. a. As used in this section, "dependent" means an enrollee's child by blood or by law who: (1) is 30 years of age or younger; (2) is unmarried; (3) has no dependent of his own; (4) is a resident of this State or is enrolled as a full-time student at an accredited public or private institution of higher education; and (5) (a) is not actually provided coverage as a named subscriber, insured, enrollee, or covered person under any other group or individual health benefits plan, group health plan, church plan or health benefits plan, or entitled to benefits under Title XVIII of the Social Security Act, Pub.L.74-271 (42 U.S.C. s.1395 et seq.) at the time dependent coverage pursuant to this section begins or will begin; and (b) there is evidence of prior, creditable coverage or receipt of benefits under a benefits plan or by law as set forth in subparagraph (a) of this paragraph. b. (1) A health maintenance organization contract that provides coverage for an enrollee's dependent under which coverage of the dependent terminates at a specific age before the dependent's 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) on or after the effective date of this section of P.L.2008, c.38, shall, upon the application of the dependent as set forth in subsection c. of this section, provide coverage to the dependent after that specific age, until the dependent's 31st birthday. (2) Nothing herein shall be construed to require: (a) coverage for services provided to a dependent before the effective date of this section of P.L.2008, c.38; or (b) that an employer or other group contract holder pay all or part of the cost of coverage for a dependent as provided pursuant to this section. c. (1) A dependent covered by an enrollee's contract, which coverage under the contract terminates at a specific age on or before the dependent's 30th birthday, may make a written election for coverage as a dependent pursuant to this section, until the dependent's 30th birthday: (a) within 30 days prior to the termination of coverage at the specific age provided in the contract; (b) within 30 days after meeting the requirements for dependent status as set forth in subsection a. of this section, when coverage for the dependent under the contract previously terminated; or (c) during an open enrollment period, as provided pursuant to the contract, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the open enrollment period. (2) (Deleted by amendment, P.L.2008, c.38) d. (1) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall consist of coverage which is identical to the coverage provided to that dependent prior to the termination of coverage at the specific age provided in the contract. If coverage is modified under the contract for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the contract, the coverage shall also be modified in the same manner for the dependent. (2) Coverage for a dependent who makes a written election for coverage pursuant to subsection c. of this section shall not be conditioned upon, or discriminate on the basis of, lack of evidence of insurability. e. (1) The enrollee's contract may require payment under the schedule of charges by the enrollee or dependent, as appropriate, subject to the approval of the Commissioner of Banking and Insurance, for any period of coverage relating to a dependent's written election for coverage pursuant to subsection c. of this section. The payment shall not exceed 102% of the applicable portion of the schedule of charges previously paid for that dependent's coverage under the contract prior to the termination of coverage at the specific age provided in the contract. (2) The applicable portion of the schedule of charges previously paid for the dependent's coverage under the contract shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the contract's rating tiers for adult and dependent coverage or family coverage, as appropriate, and single coverage, or based upon any other formula or dependent rating tier deemed appropriate by the commissioner which provides a substantially similar result. (3) Payments under the schedule of charges may, at the election of the payor, be made in monthly installments. f. Coverage for a dependent provided pursuant to this section shall be provided until the earlier of the following: (1) the date upon which the dependent is disqualified for dependent status as set forth in subsection a. of this section; (2) the date upon which coverage ceases under the contract by reason of a failure to make a timely payment under any schedule of charges required under the contract by the enrollee or dependent for coverage provided pursuant to this section. The payment under any schedule of charges shall be considered to be timely if made within 30 days after the due date or within a longer period as may be provided for by the contract; or (3) the date upon which the contract, under which coverage is provided to a dependent, ceases to provide coverage to the enrollee. Nothing herein shall be construed to permit a health maintenance organization to refuse a written election for coverage by a dependent pursuant to subsection c. of this section, based upon the dependent's prior disqualification pursuant to paragraph (1) of this subsection, other than a disqualification based on age or lack of evidence of prior, creditable coverage or receipt of benefits. g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to an enrollee by the health maintenance organization: (1) in the certificate of coverage or other equivalent document prepared for enrollees and delivered on or about the date of commencement of the enrollees' coverage; and (2) (Deleted by amendment, P.L.2008, c.38) (3) in a notice delivered to enrollees on a quarterly basis. h. This section shall apply to those contracts in which the health maintenance organization has reserved the right to change the schedule of charges. L.2005, c.375, s.6; amended 2008, c.38, s.34.
N.J. Stat. § 26:2J-11 Annual open enrollment period
a. After a health maintenance organization has been in operation 24 months, it shall have an annual open enrollment period of at least one month during which it accepts enrollees up to the limits of its capacity, as determined by the health maintenance organization, in the order in which they apply for enrollment. A health maintenance organization may apply to the commissioner for authorization to impose such underwriting restrictions upon enrollment as are necessary to preserve its financial stability, to prevent excessive adverse selection by prospective enrollees, or to avoid unreasonably high or unmarketable charges for enrollee coverage for health care services. The commissioner shall approve or deny such application within 30 days of the receipt thereof from the health maintenance organization. The Commissioner of Insurance shall certify to the commissioner the appropriateness of any requested underwriting restrictions. b. Health maintenance organizations providing or arranging for services exclusively on a group contract basis may limit the open enrollment provided for in subsection a. to all members of the group or groups covered by such contracts. c. A health maintenance organization shall notify its enrollees in writing at the time of enrollment, and include a notice in the promotional material which it distributes to prospective enrollees, that a person's choice of health benefits plan will determine his coverage until the next annual open enrollment period, regardless of the continued availability of a particular health care provider who contracts with that health maintenance organization, unless the enrollee moves his place of residence outside of the organization's designated service area. L.1973, c.337, s.11; amended 1989,c.321,s.1.
N.J. Stat. § 26:2J-11.1 Failure to agree on terms; four-month extension; notification of options
If a health maintenance organization authorized to operate in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) and a general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) with which the health maintenance organization has a contract to provide services to its enrollees, are unable to agree on the terms of a new contract upon the expiration of the current contract, the hospital and the health maintenance organization shall continue to abide by the terms of the most current contract for a period of four months from a severance date mutually agreed upon by both parties. In that event, the health maintenance organization shall promptly notify the health care providers with which it has contracted to provide services and provide notification within the four-month extension period to those of its enrollees who reside in the county in which the hospital is located or in an adjacent county in writing as to the extension of the terms of the most current contract, and shall in the notice to its enrollees advise them of the options available to them with respect to their health care coverage. L.1989, c.321, s.2.
N.J. Stat. § 26:2J-12 Complaint system
a. (1) Every health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures for the resolution of written complaints initiated by enrollees concerning health care services. (2) Each health maintenance organization shall submit to the commissioner an annual report in a form prescribed by him which shall include: (a) a description of the procedures of such complaint system; (b) the total number of written complaints handled through such complaint system and a compilation of causes underlying the complaints filed; and (c) the number, amount, and disposition of malpractice claims settled during the year by the health maintenance organization and any of the providers used by it. b. The health maintenance organization shall maintain records of written complaints filed with it concerning other than health care services and shall submit to the commissioner a summary report at such times and in such format as the commissioner may require. c. The commissioner may examine such complaint system. L.1973, c. 337, s. 12, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-13 Investments
With the exception of investments made in accordance with section 5 a. (1) and (3) hereof, the investable funds of a health maintenance organization shall be only in securities or other investments permitted by the laws of this State for the investment of assets constituting the legal reserves of life insurance companies or such other securities or investments as the commissioner may permit with the approval of the Commissioner of Insurance. L.1973, c. 337, s. 13, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-14 Protection against insolvency
Each health maintenance organization shall deposit cash or a form of guaranty or security in such amount as will assure that the obligations to the enrollees will be performed in such amount and for such time as prescribed by the commissioner, or where applicable by the Commissioner of Insurance. The commissioner may waive this requirement whenever satisfied that the assets of the organization or its contracts with insurers, hospital or medical service corporation governments, or other organizations are sufficient to reasonably assure the performance of its obligations. L.1973, c. 337, s. 14, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-15 Prohibited practices for health maintenance organization
15. a. No health maintenance organization, or representative thereof, may cause or knowingly permit the use of advertising which is untrue or misleading, solicitation which is untrue or misleading, or any form of evidence of coverage which is deceptive. For purpose of this act: (1) a statement or item of information shall be deemed to be untrue if it does not conform to fact in any respect which is or may be significant to an enrollee of, or person considering enrollment in, a health care plan; (2) a statement or item of information shall be deemed to be misleading, whether or not it may be literally untrue, if, in the total context in which such statement is made or such item of information is communicated, such statement or item of information may be reasonably understood by a reasonable person, not possessing special knowledge regarding health care coverage, as indicating any benefit or advantage or the absence of any exclusion, limitation, or disadvantage of possible significance to an enrollee of, or person considering enrollment in, a health care plan, if such benefit or advantage or absence of limitation, exclusion or disadvantage does not in fact exist; (3) an evidence of coverage shall be deemed to be deceptive if the evidence of coverage taken as a whole, and with consideration given to typography and format, as well as language, shall be such as to cause a reasonable person, not possessing special knowledge regarding health care plans and evidences of coverage therefore, to expect benefits, services, charges, or other advantages which the evidence of coverage does not provide or which the health care plan issuing such evidence of coverage does not regularly make available for enrollees covered under such evidence of coverage. b. The unfair trade practice provisions of the New Jersey insurance law (N.J.S.17B:30-1 through 22) shall be construed to apply to health maintenance organizations, health care plans and evidences of coverage except to the extent that the commissioner determines that the nature of health maintenance organizations, health care plans and evidence of coverage render such sections clearly inappropriate. c. An enrollee may not be canceled or nonrenewed except for the failure to pay the charge for such coverage, or for such other reasons as may be promulgated by the commissioner. d. No health maintenance organization, unless licensed as an insurer, may use in its name, evidence of coverage, or literature any of the words "insurance," "assurance," "casualty," "surety," "mutual," or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance, or surety corporation doing business in this State. e. A health maintenance organization shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of health care services under, a contract or certificate for health care services. The provisions of this section shall be enforced by the State Director of the Division of Consumer Affairs and, where applicable, the commissioner or the Commissioner of Insurance. Nothing in this act shall limit the powers of the Attorney General and the procedures with respect to consumer fraud in P.L.1960, c.39 (C.56:8-1 et seq.). L.1973,c.337,s.15; amended 1995,c.291,s.9.
N.J. Stat. § 26:2J-15.1 Health care services contract, exclusion, rates, terms based on genetic information prohibited
16. Every contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall not exclude any person or eligible dependent and shall not establish any rates or terms therefor on the basis of an actual or expected health condition or on the basis of any genetic characteristic. For the purposes of this section, "genetic characteristic" means any inherited gene or chromosome, or alteration thereof, that is scientifically or medically believed to predispose an individual to a disease, disorder or syndrome, or to be associated with statistically increased risk of development of a disease, disorder or syndrome. L.1996,c.126,s.16.
N.J. Stat. § 26:2J-16 Regulation of agents
The commissioner may, after notice and hearing, promulgate such reasonable rules and regulations, which have been approved by the Commissioner of Insurance, as are necessary to provide for the certification of agents. An agent as used herein means a person directly or indirectly associated with a health maintenance organization who engages in solicitation or enrollment for compensation. L.1973, c. 337, s. 16, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-17 Powers of insurers and hospital and medical service corporations
a. An insurance company licensed in this State, or a hospital or medical service corporation authorized to do business in this State, may either directly or through a subsidiary or affiliate organize and operate a health maintenance organization under the provisions of this act. Notwithstanding any other law which may be inconsistent herewith, any two or more such insurance companies, hospital or medical service corporations, or subsidiaries or affiliates thereof, may jointly organize and operate a health maintenance organization. b. Notwithstanding any provision of Title 17 of the Revised Statutes and Title 17B of the New Jersey Statutes, an insurer or a hospital or medical service corporation may contract with a health maintenance organization to provide insurance or protection against the cost of care furnished through health maintenance organizations and to provide coverage in the event of the failure of health maintenance organization to meet its obligations. The enrollees of a health maintenance organization constitute a permissible group under such laws. Among other things, under such contracts, the insurer or hospital or medical service corporation may make benefit payments to health maintenance organizations for health care services rendered by providers. L.1973, c. 337, s. 17, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-18 Examinations
a. Not less frequently than once every 3 years the commissioner may make an examination concerning the quality of health care services and other affairs of the health maintenance organization and providers with whom such organization has contracts, agreements, or other arrangements. The commissioner may make such examination at any time. b. Every health maintenance organization and provider shall submit its books and records to such examinations. For the purpose of examinations, the commissioner may administer oaths to, and examine the officers and agents of the health maintenance organization and the principals of such providers concerning their business. c. The expenses of examinations under this section up to $1,000.00 annually shall be assessed against the organization being examined and such amount shall be remitted to the commissioner. d. In lieu of such examination, the commissioner may accept the report of an examination made by the Commissioner of Health or Commissioner of Insurance of another state. L.1973, c. 337, s. 18, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-18.1 Examination of HMO by Commissioner of Banking and Insurance.
20. The Commissioner of Banking and Insurance may conduct an examination of a health maintenance organization in accordance with the procedures provided in P.L.1993, c.236 (C.17:23-20 et seq.) as often as he deems necessary in order to protect the interests of providers, contract holders, members, and the residents of this State. An organization shall make its relevant books and records available for examination by the Commissioner of Banking and Insurance, and retain its records in accordance with a schedule established by the Commissioner of Banking and Insurance by regulation. The reasonable expenses of the examination shall be borne by the organization being examined. In lieu of such examination, the Commissioner of Banking and Insurance may accept the report of an examination made by the commissioner of another state. L.1997,c.192,s.20; amended 2005, c.65, s.7.
N.J. Stat. § 26:2J-18.2 Definitions relative to risk based capital requirements for HMOs.
1. As used in sections 1 through 5 of P.L.2005, c.65 (C.26:2J-18.2 et seq.): "Commissioner" means the Commissioner Banking and Insurance. "Health maintenance organization" means an entity authorized to transact business in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.). L.2005,c.65,s.1.
N.J. Stat. § 26:2J-18.3 Increase of capital, surplus; methods, procedures.
2. The commissioner may increase the amount of capital or surplus required of a health maintenance organization, or subsequently revise or redetermine that increase, using appropriate methods and procedures established by rules and regulations adopted by the commissioner, in order to provide adequate protection against risks affecting the health maintenance organization's financial condition that are not adequately or fully covered by its reserves or other assets, but under no circumstances shall a health maintenance organization's capital or surplus be less than the capital or surplus required pursuant to regulation as prescribed by the commissioner; provided, however, that any increase required by a subsequent revision or redetermination pursuant to this section, shall be made only after a formal departmental hearing, on the record, unless that hearing is waived by the affected health maintenance organization. All matters pertaining to a hearing or to an increase in capital or surplus pursuant to this section shall be confidential and not subject to subpoena or public inspection, except to the extent that the commissioner finds release of that information necessary to protect the public. The hearing shall be initiated within 20 days after written notice to the health maintenance organization. Any declaration regarding an increase required by a subsequent revision or redetermination shall contain findings specifying the factors deemed significant in regard to the particular health maintenance organization, and shall set forth the reasons supporting the increase of capital or surplus ordered by the commissioner. In determining any increase, revision or redetermination in the amount of capital or surplus, the commissioner shall consider the risks of: a. Increases or decreases in the frequency and severity of losses under normal operating conditions, as well as increases or decreases in those values, above or below the levels contemplated by the rates that it charged for coverage and above or below those reasonably expected under normal conditions; b. Increases or decreases in expenses under normal operating conditions, as well as increases or decreases in those values, above or below the levels contemplated by the rates it charged for coverage and above or below those reasonably expected under normal conditions; c. Increases or decreases in the value of, or return on, invested assets under normal operating conditions, as well as increases or decreases in those values, above or below those levels anticipated under normal conditions; d. Changes in economic, social and market conditions that could adversely or favorably affect the financial condition of the health maintenance organization, including conditions that would make liquidity more or less important than contemplated and would prevent or facilitate timely investments or force or prohibit untimely sales of assets; and e. Any other contingencies, including reinsurance and unfunded or extra contractual obligations, which may affect the health maintenance organization's financial condition. L.2005,c.65,s.2.
N.J. Stat. § 26:2J-18.4 Factors in determining change in capital, surplus.
3. In determining any increase, revision or redetermination in the capital or surplus of a health maintenance organization pursuant to the provisions of section 2 of P.L.2005, c.65 (C.26:2J-18.3) the commissioner shall take into account the following factors: a. Methods and techniques used to measure risk exposure and variability; b. The information available relating to the magnitude of the various risks described in section 2 of P.L.2005, c.65 (C.26:2J-18.3); c. The extent to which risks described in section 2 of P.L.2005, c.65 (C.26:2J-18.3) are independent or interrelated, and whether any dependency is direct or inverse; d. The extent to which the health maintenance organization has provided protection against contingencies in ways other than the establishment of surplus, including, but not limited to: redundancy of premiums; margin in reserves and liabilities; adjustability of contracts pursuant to the terms of the contracts; voluntary or mandatory investment valuation reserves; reinsurance; the use of conservative actuarial assumptions to provide a margin of security; reserve adjustments after rate increases for policies written at earlier and less adequate rates; contingency or catastrophe reserves; and diversification of assets and underwriting risk; and e. Any other relevant factors, including the National Association of Insurance Commissioners' reports and independent judgments of the soundness of the health maintenance organization's financial condition, as evidenced by the rating and reports of reliable professional financial services. L.2005,c.65,s.3.
N.J. Stat. § 26:2J-18.5 Noncompliance, penalties.
4. The commissioner may suspend or revoke the authority to do business in this State of any health maintenance organization that does not comply with the provisions of P.L.2005, c.65 (C.26:2J-18.2 et al.). L.2005,c.65,s.4.
N.J. Stat. § 26:2J-18.6 Regulations.
5. The commissioner may promulgate regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of P.L.2005, c.65 (C.26:2J-18.2 et al.). L.2005,c.65,s.5.
N.J. Stat. § 26:2J-19 Suspension or revocation of certificate of authority
a. The commissioner may suspend or revoke any certificate of authority issued to a health maintenance organization under this act if he finds that any of the following conditions exist: (1) The health maintenance organization is operating in a manner significantly contrary to that described in section 3, hereof, unless amendments to such submissions have been filed with the commissioner; (2) The health maintenance organization issues evidence of coverage which does not comply with the requirements of section 8 hereof; (3) the health maintenance organization does not provide or arrange for basic health care services; (4) the commissioner finds that: (a) the health maintenance organization does not meet the requirements of section 4 a. (2), hereof; or (b) the health maintenance organization is unable to fulfill its obligations to furnish health care services. (5) the health maintenance organization is no longer financially responsible and may reasonably be expected to be unable to meet its obligations to enrollees or prospective enrollees; (6) the health maintenance organization has failed to implement a mechanism affording the enrollees an opportunity to participate in matters of policy and operation under section 6, hereof; (7) the health maintenance organization has failed to implement the complaint system required by section 12, hereof, in a manner to reasonably resolve valid complaints; (8) the continued operation of the health maintenance organization would be hazardous to the health and safety of its enrollees; (9) the health maintenance organization has otherwise failed to substantially comply with this act; or (10) the health maintenance organization, or any person on its behalf, has advertised or merchandised its services in an untrue, misrepresentative, misleading, deceptive or unfair manner. b. A certificate of authority shall be suspended or revoked only after compliance with the requirements of section 21, hereof. c. When the certificate of authority of a health maintenance organization is suspended, the health maintenance organization shall not, during the period of such suspension, enroll any additional enrollees except newborn children or other newly acquired dependents of existing enrollees, and shall not engage in any advertising or solicitation whatsoever. d. When the certificate of authority of a health maintenance organization is revoked, such organization shall proceed, immediately following the effective date of the order of revocation, to dissolve its structure, and shall conduct no further business except as may be essential to the orderly conclusion of the affairs of such organization. It shall engage in no further advertising or solicitation whatsoever. The commissioner or where applicable the Commissioner of Insurance may, by written order, permit such further operation of the organization as he may find to be in the best interest of enrollees, to the end that enrollees will be afforded the greatest practical opportunity to obtain continuing health care coverage. L.1973, c. 337, s. 19, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-21 Regulation
The commissioner may, upon notice and hearing, promulgate reasonable rules and regulations, as are necessary or proper to carry out the provisions of this act. Where applicable, such rules and regulations shall be promulgated after consultation with the Commissioner of Insurance. Such rules and regulations shall specify those determinations in this act which are to be made by the Commissioner of Insurance and shall be subject to review in accordance with the Administrative Procedure Act, P.L.1968, c. 410 (C. 52:14B-1 et seq.). L.1973, c. 337, s. 21, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-22 Administrative procedures
a. When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist, or that grounds for the suspension or revocation of a certificate of authority exist, he shall notify the health maintenance organization and the Commissioner of Insurance in writing specifically stating the grounds for denial, suspension, or revocation and fixing a time of at least 20 days thereafter for a hearing on the matter. b. The Commissioner of Insurance, or his designated representative, shall be in attendance at the hearing and shall participate in the proceedings. The recommendation and findings of the Commissioner of Insurance with respect to matters relating to the doing of an insurance business or contract with an insurer or hospital or medical services corporation, provided in connection with any decision regarding denial, suspension, or revocation of a certificate of authority, shall be conclusive and binding upon the commissioner. After such hearing, or upon the failure of the health maintenance organization to appear at such hearing, the commissioner shall take action as is deemed advisable on written findings which shall be mailed to the health maintenance organization with a copy thereof to the Commissioner of Insurance. The action of the commissioner and the recommendation and findings of the Commissioner of Insurance and the levy of any administrative penalty shall be subject to judicial review in accordance with chapter 34 of Title 17B of the New Jersey Statutes. c. The provisions of the Administrative Procedure Act, P.L.1968, c. 410 (C. 52:14B-1 et seq.) of this State shall apply to proceedings under this section to the extent they are not in conflict with subsections a. and b. of this section. L.1973, c. 337, s. 22, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-23 Fees.
23. Every health maintenance organization subject to this act shall pay to the commissioner the following fees: a. for filing an application for a certificate of authority or amendment thereto, $100.00; b. for filing each annual report, $10.00; and c. for the purpose of supporting the activities of the Department of Banking and Insurance associated with the regulation of health maintenance organizations, $1.50 per life per year, with payment being made annually no later than July 15 for the preceding calendar year. Payments made by a health maintenance organization pursuant to this act shall not in any way reduce payments that may be owed by a health maintenance organization pursuant to P.L.1995, c.156 (C.17:1C-19 et seq.) and subsequent amendments thereto. No such payment shall be required for any per life per year that is funded through the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) or the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). In accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), the commissioner may promulgate rules and regulations directing that additional fees be paid. From fees collected under the provisions of subsection c. of this section, the Legislature shall in each fiscal year appropriate to the community health law project the sum of $100,000 to fund a grant in support of a program to provide any senior citizen resident of this State who is covered as an enrollee in or beneficiary of a health plan administered by a health maintenance organization with information concerning the person's rights under the program and assistance with the procedures for receiving the benefits to which the person is entitled under the program. L.1973, c.337, s.23; amended 2002, c.34, s.18; 2012, c.17, s.277.
N.J. Stat. § 26:2J-24 Administrative penalty; enforcement
24. a. The commissioner may, in lieu of suspension or revocation of a certificate of authority under section 18 hereof, levy an administrative penalty in an amount not less than $250 nor more than $10,000 for each day that the health maintenance organization is in violation of P.L.1973, c.337 (C.26:2J-1 et seq.), if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the health maintenance organization has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the conditions which gave rise to the violation, and fails to do so within the time allowed. Any such penalty may be recovered in a summary proceeding pursuant to "the penalty enforcement law," N.J.S.2A:58-1 et seq. b. Any person who violates this act is a disorderly person and shall be prosecuted and punished pursuant to the "disorderly persons law," subtitle 12 of Title 2A of the New Jersey Statutes. c. (1) If the commissioner or the Commissioner of Banking and Insurance shall for any reason have cause to believe that any violation of this act has occurred or is threatened, the commissioner or Commissioner of Banking and Insurance may give notice to the health maintenance organization and to the representatives, or other persons who appear to be involved in such suspected violation, to arrange a conference with the alleged violators or their authorized representatives for the purpose of attempting to ascertain the facts relating to such suspected violation, and, in the event it appears that any violation has occurred or is threatened, to arrive at an adequate and effective means of correcting or preventing such violation. (2) Proceedings under this subsection c. shall not be governed by any formal procedural requirements, and may be conducted in such manner as the commissioner or the Commissioner of Banking and Insurance may deem appropriate under the circumstances. d. (1) The commissioner or the Commissioner of Banking and Insurance may issue an order directing a health maintenance organization or a representative of a health maintenance organization to cease and desist from engaging in any act or practice in violation of the provisions of this act. (2) Within 20 days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this act have occurred. Such hearings shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and judicial review shall be available as provided therein. e. In the case of any violation of the provisions of this act, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection d. of this section, the commissioner may institute a proceeding to obtain injunctive relief, in accordance with the applicable Court Rules. L.1973,c.337,s.24; amended 1997,c.192,s.29.
N.J. Stat. § 26:2J-25 Statutory construction and relationship to other laws.
25. Statutory construction and relationship to other laws. a. Except as otherwise provided in this act, provisions of the insurance law and provisions of hospital, medical or health service corporation laws shall not be applicable to any health maintenance organization granted a certificate of authority under this act. This provision shall not apply to an insurer or hospital, medical or health service corporation licensed and regulated pursuant to the insurance laws or the hospital, medical or health service corporation laws of this State except with respect to its health maintenance organization activities authorized and regulated pursuant to this act. Charges paid by or on behalf of enrollees of a health maintenance organization with respect to health care services shall not be subject to taxation by the State or any of its political subdivisions, except as otherwise provided in section 3 of P.L.2004, c.49 (C.26:2J-47). b. Solicitation of enrollees by a health maintenance organization granted a certificate of authority, or its representatives, shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals. c. Any health maintenance organization authorized under this act shall not be deemed to be practicing medicine and shall be exempt from the provisions of chapter 9 of Title 45, Medicine and Surgery, of the Revised Statutes relating to the practice of medicine. d. Except as provided in P.L.2001, c.187 (C.2A:53A-30 et al.), no person participating in the arrangements of a health maintenance organization other than the actual provider of health care services or supplies directly to enrollees and their families shall be liable for negligence, misfeasance, nonfeasance or malpractice in connection with the furnishings of such services and supplies. The provisions of this subsection shall not be construed to eliminate any cause of action against a health maintenance organization otherwise provided by law. e. A health maintenance organization shall be subject to the provisions of P.L.1970, c.22 (C.17:27A-1 et seq.), including those relating to merger or acquisition of control. L.1973,c.337,s.25; amended 2001, c.2, s.1; 2001, c.187, s.8; 2004, c.49, s.4; 2005, c.129, s.1.
N.J. Stat. § 26:2J-26 Filings and reports as public documents.
26. Filings and reports as public documents. All applications, filings and reports required under this act shall be treated as public documents and, except for any examination being conducted pursuant to section 20 of P.L.1997, c.192 (C.26:2J-18.1), any matter pertaining to a change in capital or surplus pursuant to the provisions of P.L.2005, c.65 (C.26:2J-18.2 et al.) and contracts referred to in paragraphs (4) and (5) of subsection c. of section 3 of P.L.1973, c. 337 (C.26:2J-3), shall not be considered to be confidential. L.1973,c.337,s.26; amended 2005, c.65, s.6.
N.J. Stat. § 26:2J-27 Confidentiality of medical information
Any data or information pertaining to the diagnosis, treatment, or health of any enrollee or applicant obtained from such enrollee or from any provider by any health maintenance organization shall be held in confidence and shall not be disclosed to any person except to the extent that it may be necessary to carry out the purposes of this act; or upon the express consent of the enrollee or applicant; or pursuant to statute or court order for the production of evidence or the discovery thereof; or in the event of claim or litigation between such enrollee and the health maintenance organization wherein such data or information is pertinent. A health maintenance organization shall be entitled to claim any statutory privileges against such disclosure which the provider who furnished such information to the health organization is entitled to claim. L.1973, c. 337, s. 27, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-28 Commissioner of health's authority to contract
The commissioner or where applicable the Commissioner of Insurance, in carrying out his obligations under sections 4 a. (2), and 18 a. hereof, may contract with qualified persons to make recommendations concerning the determinations required to be made by him. Such recommendations may be accepted in full or in part by the commissioner or Commissioner of Insurance. L.1973, c. 337, s. 28, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-29 Enrollment of State employees
Any employee of the State or any subdivision of the State or any institution supported in whole or in part by the State may elect to enroll in a health maintenance organization and have all deductions from his salary or wages and all contributions being paid by his employer to any health insurer paid instead to a health maintenance organization; provided, however, in no event, shall an employer under this section make a contribution to any alternative health benefits program greater than the contribution being made to any health plan pursuant to a contract in existence on the effective date of this act. Any such employee shall at least annually be allowed to choose an alternative health benefits program made available through his employer. L.1973, c. 337, s. 29, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-30 Severability
If any section, term, or provision of this act shall be adjudged invalid for any reason, such judgment shall not affect, impair, or invalidate any other section, term, or provision of this act, but the remaining sections, terms, and provisions shall be and remain in full force and effect. L.1973, c. 337, s. 30, eff. Dec. 27, 1973.
N.J. Stat. § 26:2J-31 Definitions
1. As used in this act: "Applicant" means any individual who seeks enrollment with a health maintenance organization for the purpose of obtaining medicare supplement health care services. "Commissioner" means the Commissioner of Insurance. "Department" means the Department of Insurance. "Enrollee" means an individual who is enrolled with a health maintenance organization. "Evidence of coverage" means any booklet, certificate, agreement or contract issued to an enrollee setting out the services and other benefits to which he is entitled. "Health care services" means those services, including, but not limited to, inpatient hospital and physician care, and outpatient medical services, as set forth in the evidence of coverage. "Health maintenance organization" means any person which, directly or through contracts with providers, furnishes health care services on a prepaid basis to enrollees in a designated geographic area in this State pursuant to the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.). "Medicare" means the program established by the "Health Insurance for the Aged Act," Title XVIII of the "Social Security Act," Pub.L. 89-97, as then constituted or later amended (42 U.S.C. s.1395 et seq.). "Medicare supplement contract" means a group or individual contract or plan which is advertised, marketed or designed primarily as providing, or is otherwise held out to provide, medicare supplement health care services and under which an individual is enrolled, other than a contract issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm or a contract issued under a demonstration project authorized pursuant to the "Health Insurance for the Aged Act," 42 U.S.C. s.1395 et seq. The term does not include health care services provided pursuant to a contract or plan issued to one or more employers or labor organizations, or to the trustees of a fund established by one or more employers or labor organizations, or combination thereof, for employees or former employees of the employers, or a combination thereof, or for members or former members, or a combination thereof, of the labor organizations. "Medicare supplement evidence of coverage" means an evidence of coverage delivered to an enrollee who has medicare supplement health care services coverage under a medicare supplement contract. "Medicare supplement health care services" means health care services which supplement medicare, provided under a medicare supplement contract as set forth in a medicare supplement evidence of coverage. "Provider" means any physician, hospital or other person which is licensed or otherwise authorized in this State to furnish health care services. L.1992,c.164,s.1.
N.J. Stat. § 26:2J-32 Applicability of act
2. Except as otherwise specifically provided: a. This act shall apply to all medicare supplement health care services provided pursuant to a medicare supplement contract or evidence of coverage delivered or issued for delivery in this State. b. This act shall not apply to any health maintenance organization contract or evidence of coverage, including group conversion plans, provided to medicare eligible persons that are not advertised, marketed, designed primarily as or otherwise held out to provide medicare supplement health care services. L.1992,c.164,s.2.
N.J. Stat. § 26:2J-33 Avoidance of duplication of benefits, regulations
3. a. No medicare supplement contract or evidence of coverage shall provide for health care services which duplicate any benefits provided by medicare. b. The commissioner shall promulgate regulations to establish specific standards for the provisions to be contained in any medicare supplement contract or evidence of coverage, which shall be in addition to and in accordance with the applicable laws of this State. The regulations may provide, but shall not be limited to: (1) Terms of renewability; (2) Initial and subsequent conditions of eligibility; (3) Non-duplication of coverage; (4) Probationary periods; (5) Benefit limitations, exceptions and reductions; (6) Elimination periods; (7) Requirements for replacement; (8) Recurrent conditions; and (9) Definition of terms. c. The commissioner may promulgate regulations that specify prohibited medicare supplement contract or evidence of coverage provisions not otherwise specifically authorized by statute which, in the opinion of the commissioner, are unjust, unfair or unfairly discriminatory to any applicant for, or enrollee with, medicare supplement health care services coverage. L.1992,c.164,s.3.
N.J. Stat. § 26:2J-34 Coverage for preexisting condition
4. Notwithstanding any other provision of law to the contrary, a medicare supplement contract or evidence of coverage shall not deny medicare supplement health care services for losses incurred more than six months from the effective date of enrollment for a preexisting condition. The contract or evidence of coverage shall not define a preexisting condition more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a physician within six months of the effective date of enrollment. L.1992,c.164,s.4.
N.J. Stat. § 26:2J-35 Regulations
5. The commissioner shall promulgate regulations to effectuate and enforce the provisions of this act and any regulations which are necessary to conform medicare supplement health care services provided under a medicare supplement contract or evidence of coverage with federal law. These regulations shall include, but not be limited to: a. Establishment of minimum standards for benefits, claim payments, marketing and reporting practices and compensation arrangements; b. Establishment of a uniform methodology for calculating and reporting loss ratios, and requiring refunds or credits if the medicare supplement contracts do not meet loss ratio requirements; c. Establishment of a process for filing of all requests for premium increases and rate changes which may include public hearings as determined appropriate by the commissioner prior to approval of any premium increases; d. Assurance of access by the public to policy, premium and loss ratio information; and e. Establishment of standards for Medicare Select contracts at such time as this State is authorized under federal law to authorize Medicare Select contracts. L.1992,c.164,s.5.
N.J. Stat. § 26:2J-36 Authorization for health maintenance organization to offer, provide medicare supplement health care services
6. No health maintenance organization shall offer or provide medicare supplement health care services in this State without authorization by the commissioner. The commissioner shall grant authorization if he determines that the health maintenance organization has the financial and operational capability to provide such services. In making a determination, the commissioner may consider, but shall not be limited to, the following: a. The number of enrollees; b. The geographic area to be serviced; c. The current and prospective financial condition of the health maintenance organization; d. The anticipated impact on the health maintenance organization of providing medicare supplement health care services in addition to other services which it provides. L.1992,c.164,s.6.
N.J. Stat. § 26:2J-37 Submission of underlying plan; rate filings
7. a. No health maintenance organization authorized pursuant to section 6 of this act shall deliver or issue for delivery in this State any medicare supplement contract or evidence of coverage or any application or notification used in connection with the issuance or continuance of a medicare supplement contract or evidence of coverage unless the form of which, including a copy of the underlying plan, has been submitted to and filed by the commissioner pursuant to the provisions of this subsection. (1) At the expiration of 60 days after submission a form shall be deemed filed unless prior thereto it has been affirmatively filed or disapproved for filing by the commissioner. (2) No form which is disapproved for filing by the commissioner during the 60-day period, may be delivered or issued for delivery in this State unless and until the disapproval for filing is withdrawn. Any disapproval shall be subject to review in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). Any form which is filed by the commissioner or deemed filed may be delivered or issued for delivery in this State until such time as any subsequent withdrawal of the filing by the commissioner, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). (3) The commissioner may extend the 60-day period provided in paragraph (1) of this subsection for not more than 60 additional days by giving written notice of extension before the expiration of the initial 60-day period. In the event of an extension, all of the provisions of this subsection, except this provision for an extension, relating to the initial 60-day period shall apply to the extended period instead of the initial 60-day period. (4) The disapproval for filing or the withdrawal of the filing of any form by the commissioner shall state in writing the grounds therefor in such detail as is reasonable to inform the health maintenance organization of the reasons for withdrawal or disapproval. (5) The provisions of this subsection shall not apply to documents which relate only to the manner of distribution of services or to the reservation of rights and services under the medicare supplement contract or evidence of coverage and which are used at the request of the enrollee. (6) The disapproval by the commissioner of any form submitted for filing pursuant to the provisions of this subsection may be on the ground that the form contains provisions which are unjust, unfair, inequitable, misleading or contrary to law or to the public policy of this State. b. Every health maintenance organization providing medicare supplement health care services to a resident of this State shall file annually with the commissioner its rates, rating schedule and supporting documentation demonstrating that it is in compliance with the applicable loss ratio standards of this State. All filings of rates and rating schedules shall be certified by a qualified actuary and shall demonstrate that the actual and expected costs in relation to services provided comply with the requirements of this act and any rule or regulation promulgated hereunder. As used in this subsection, "qualified actuary" means a person, in good standing, who is a member of the American Academy of Actuaries, a fellow of the Casualty Actuarial Society, or a person who has otherwise demonstrated actuarial competence to the satisfaction of the commissioner. c. Services provided under a medicare supplement contract or evidence of coverage shall be expected to return to enrollees services or other benefits which are reasonable in relation to the premium or other fee charged. The commissioner shall promulgate regulations to establish minimum standards for loss ratios under medicare supplement contracts or evidences of coverage on the basis of paid medicare supplement health care expenses and written earned premiums and fees in accordance with accepted actuarial principles and practices. L.1992,c.164,s.7.
N.J. Stat. § 26:2J-38 Outline of coverage delivered to applicant
8. a. In order to provide for full and fair disclosure in the sale of medicare supplement contracts or evidences of coverage, no medicare supplement contract or evidence of coverage shall be delivered or issued for delivery in this State unless an outline of coverage is delivered to the applicant at the time application is made. b. The commissioner shall prescribe the format and content of the outline of coverage required by subsection a. of this section. For the purposes of this section, "format" means style, arrangement and overall appearance, including the size, color and prominence of the font used, paper size and weight and the arrangement of text and captions. The outline of coverage shall include: (1) A description of the principal medicare supplement health care services provided; (2) A statement of any applicable exceptions, reductions and limitations in the available medicare supplement health care services; (3) A statement of the renewal provisions, including any reservation by the health maintenance organization of the right to change premiums or other fees; and (4) A statement that the outline of coverage is a summary of the medicare supplement contract or evidence of coverage issued or applied for and that the contract or evidence of coverage should be consulted to determine the governing contractual provisions. c. The commissioner may require by regulation the publication of forms and an informational brochure with a standardized format and content, to serve as an aid in the selection of appropriate coverage, if any, by those eligible for medicare, and to aid the consumer in improving his understanding of medicare benefits. Except in the case of direct response solicitation for medicare supplement health care services, the commissioner may require by regulation that the informational brochure be provided, concurrently with delivery of the outline of coverage, to all prospective enrollees eligible for medicare. With respect to direct response solicitation for medicare supplement health care services, the commissioner may require by regulation that the prescribed brochure be provided upon request to any prospective enrollee eligible for medicare, but in no event later than the time the medicare supplement contract or evidence of coverage is delivered. d. The commissioner may promulgate regulations for captions or notice requirements for all contracts and evidences of coverage delivered or issued for delivery to persons eligible for medicare to inform prospective enrollees that the particular contract or evidence of coverage does not provide medicare supplement health care services. These notice requirements shall not apply to medicare supplement contracts or evidences of coverage or to contracts issued pursuant to a contract under 42 U.S.C. s.1395l or 42 U.S.C. s.1395mm. e. The commissioner may further promulgate regulations to govern the full and fair disclosure of information in connection with the replacement of contracts or evidences of coverage by persons eligible for medicare. L.1992,c.164,s.8.
N.J. Stat. § 26:2J-39 30-day return provision, refunds
9. Notice shall be prominently printed on the first page of each medicare supplement contract and evidence of coverage stating in substance that the applicant shall have the right to return the contract or evidence of coverage within 30 days of its delivery and to have any premium or other fee refunded if, after examination of the contract or evidence of coverage, the applicant is not satisfied for any reason. Refunds made pursuant to this section shall be made in a timely manner and shall be paid directly to the applicant. L.1992,c.164,s.9.
N.J. Stat. § 26:2J-40 Filing of copy of advertising materials, regulations
10. a. Every health maintenance organization shall file with the department a copy of all advertising materials to be used in promoting medicare supplement health care services to which residents of this State will have access, and through which the health maintenance organization intends, or by implication purports to the reasonable, targeted consumer its intent, to make such services available for enrollment in this State. The requirements of this section shall apply to all advertisements in any medium whether in print or by means of television or radio broadcast. Filings shall be made at least 30 days prior to the date on which the advertisement is to be used in this State, or made accessible to residents of this State. b. The commissioner may, in the public interest, promulgate regulations governing medicare supplement health care services advertising including, but not limited to, specific filing procedures, standards upon which review may be based, celebrity endorsements, unfair practices and review and disapproval procedures. c. Notwithstanding the provisions of subsection b. of this section, the commissioner may disapprove any advertisement for use in this State at any time if he determines that the advertisement misrepresents the product, misleads the targeted consumer, uses a strategy which involves scare tactics, unnecessarily confusing data or representations, false or fraudulent statements or otherwise violates any applicable law of this State or regulation promulgated thereunder. L.1992,c.164,s.10.
N.J. Stat. § 26:2J-41 Additional remedies
11. In addition to any other applicable penalties for violation of the relevant provisions of law, the commissioner may require a health maintenance organization violating the provisions of this act to cease marketing any medicare supplement contract or evidence of coverage in this State which is related directly or indirectly to the violation, require the health maintenance organization to take such action as is necessary to comply with the provisions of this act, or both. L.1992,c.164,s.11.
N.J. Stat. § 26:2J-42 Health maintenance organization contract; compliance
24. No health maintenance organization contract, evidence of coverage, or other form subject to the filing requirements of P.L.1973, c.337 (C.26:2J-1 et seq.) or application for that coverage, if a written application is required and is to be made a part of that contract or evidence of coverage, or a printed rider or an endorsement for use with that contract or evidence of coverage, shall be delivered or issued for delivery in this State unless its provisions comply with all of the requirements of P.L.1973, c.337 (C.26:2J-1 et seq.) and any regulations adopted or guidelines published by the Commissioner of Insurance consistent with the requirements thereof. Any contract, evidence of coverage, application, rider, or endorsement issued or delivered in this State that is not in compliance with that law or regulations or guidelines shall be deemed to be in compliance with the requirements and shall be interpreted by the courts and among the persons affected by the contract or evidence of coverage as if that form were in compliance with the requirements; except that this provision shall not relieve the health maintenance organization from any penalty that may be imposed for violation of this act or any provision of P.L.1973, c.337 (C.26:2J-1 et seq.). L.1995,c.73,s.24.
N.J. Stat. § 26:2J-43 Filing of contract or related form
25. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), any health maintenance organization contract or evidence of coverage or related form subject to the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.), including any application, rider, or endorsement which is made a part of those contracts or evidences of coverage shall be filed with the Commissioner of Insurance for approval as provided in this section. Any such contract or evidence of coverage, and any related form, except those certified pursuant to section 26 of this act, shall be filed with the Commissioner of Insurance for approval pursuant to this section. b. Any contract, evidence of coverage or related form filed with the Commissioner of Insurance for approval pursuant to this section shall be deemed approved upon the expiration of 60 days after the submission of the form unless disapproved in writing by the Commissioner of Insurance within that time. Any such disapproval shall be based only on the specific provisions of applicable statutes, regulations adopted by the Commissioner of Insurance, or guidelines published by the Commissioner of Insurance as of the effective date of this act, with regard to forms of that type. A disapproved contract, evidence of coverage or related form may be resubmitted. c. Any contract, evidence of coverage or related form filed for approval pursuant to this section and disapproved by the Commissioner of Insurance before the expiration of 60 days after its submission shall be deemed withdrawn at the expiration of 60 days after the transmittal of the specific objections of the Commissioner of Insurance unless the filer submits a complete written response to all of the objections of the Commissioner of Insurance within the 60 day period. d. A contract, evidence of coverage or related form, resubmitted in response to the objections of the Commissioner of Insurance pursuant to subsection b. of this section, shall be deemed approved upon the expiration of 30 days after its resubmission unless disapproved in writing by the Commissioner of Insurance within that time. No disapproval by the Commissioner of Insurance of a resubmission shall be based on any objection not specified by the Commissioner of Insurance in the initial disapproval of the filing, except that the Commissioner of Insurance may disapprove that form based upon any new provisions introduced in the resubmission or if in addressing the specified objections cited in the disapproval transmission of the Commissioner of Insurance, the health maintenance organization changes or modifies any substantive provisions of the form. Any form resubmitted for approval pursuant to this section and disapproved by the Commissioner of Insurance before the expiration of 30 days after its submission shall be deemed withdrawn at the expiration of 30 days after the transmittal of the specific objections of the Commissioner of Insurance, unless the filer submits a complete written response to all of the objections of the Commissioner of Insurance regarding the submission within the 30 day period. e. With respect to all types of contracts, evidences of coverage or related forms required to be filed pursuant to this section and currently on file with and approved by the Commissioner of Insurance upon enactment of this act, the Commissioner of Insurance shall propose regulations, which may be amended or modified by the Commissioner of Insurance from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein, not later than 180 days after enactment of this act. Any such regulation shall be adopted not later than 180 days after it is proposed. With respect to any type of form not then on file with the Commissioner of Insurance but filed subsequent to enactment of this act, the Commissioner of Insurance shall propose regulations, which may be amended or modified by the Commissioner of Insurance from time to time after adoption, concerning any actuarial or form requirements consistent with applicable statutory provisions but not specified therein within 120 days after the form is approved or deemed approved by the Commissioner of Insurance pursuant to this section. Any such regulation shall be adopted not later than 180 days after it is proposed. The Commissioner of Insurance may issue bulletins which are interpretive of existing regulations consistent with statutory provisions, with respect to any type of contract or evidence of coverage form that may be certified pursuant to section 26 of this act. Nothing in this section shall preclude a health maintenance organization from filing a certifiable contract or evidence of coverage or related form for approval by the Commissioner of Insurance. f. Any such form which is filed with the Commissioner of Insurance or deemed filed may be so delivered or issued for delivery until such time as any subsequent withdrawal of the filing by the Commissioner of Insurance, following an opportunity for a hearing held in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and any rules adopted thereunder, becomes final in accordance therewith. g. For purposes of this section: "days" means calendar days, except that when the last day of any specified time period is a Saturday, Sunday, or State holiday, then the time period shall end on the next following business day. With respect to any specified time period pertaining to correspondence between a health maintenance organization and the Commissioner of Insurance, the time period shall commence on the date that such correspondence is postmarked or submitted to a private delivery service. h. The Commissioner of Insurance, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations as may be necessary to effectuate the purposes of this section. L.1995,c.73,s.25.
N.J. Stat. § 26:2J-44 Contract forms; certification memorandum
26. a. Pursuant to the provisions of this section, a health maintenance organization authorized to do business in this State may file with the Commissioner of Insurance and use, in accordance with subsection d. of this section, any health maintenance organization contract, evidence of coverage or related form that is stipulated by the Commissioner of Insurance to be of a kind or type eligible for file and use pursuant to subsection b. of this section. The form shall be accompanied by a certification memorandum which includes a statement that it is filed in accordance with the provisions of this section, and which is executed by a responsible officer of the health maintenance organization who certifies that the form being filed is in conformance with the law and regulation applicable to that type or kind of form as specified in a certification form to be determined by the Commissioner of Insurance. If the Commissioner of Insurance determines that the form being filed does not conform with the law or regulation applicable to that type or kind of form, the Commissioner of Insurance shall notify the health maintenance organization of his objections in writing and may disapprove that form for further use in New Jersey. b. Contracts and evidence of coverage forms, including related endorsements, riders and application forms, eligible for certification pursuant to this section shall include, but not be limited to, certain categories of individual and group health maintenance organization contracts and evidences of coverage which the Commissioner of Insurance shall define by regulation. c. The certification memorandum shall be signed and acknowledged by a responsible officer of the health maintenance organization. The acknowledgment by that officer shall be done in the same manner in which documents for recording instruments conveying or affecting interests in real estate in this State must be acknowledged to be eligible for recording, or in such other manner as specified by the Commissioner of Insurance by regulation from time to time. d. Upon receipt of an acknowledgment from the Commissioner of Insurance that the form and a certification memorandum which conforms to the requirements of this section have been received, the form so submitted may be used by the health maintenance organization. e. (1) Improper certification shall subject a health maintenance corporation submitting such improper certification to a fine not to exceed $50,000 and, in addition, a maximum penalty of $1,000 per contract or evidence of coverage issued on a form determined to be improperly certified pursuant to the provisions of this section. The Commissioner of Insurance shall promulgate a schedule of penalties to be applied pursuant to this section. In determining the amount of any penalty to be imposed, the Commissioner of Insurance shall consider the severity of the violation based upon the potential adverse impact to the public and whether it is the filer's first violation of this section. (2) If, after notice and a hearing pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), a health maintenance organization is found by the Commissioner of Insurance to be in violation of this section, the form may be disapproved, and in addition to any other penalties that may be imposed pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), the Commissioner of Insurance may bar that health maintenance organization from participating in the certification process pursuant to this section for a period not to exceed one year. f. The Commissioner of Insurance shall hold a hearing annually, or more often, for the purpose of adopting regulations to define the specific forms eligible for certification pursuant to this section. Initial regulations shall be adopted pursuant to this section no later than 180 days after enactment of this act. g. For purposes of this section: (1) "a responsible officer of the health maintenance organization" means a corporate officer of the level of vice president or higher, or of equivalent title within the health maintenance organization's structure, who is either the actuary of the health maintenance organization with responsibility for the type of form filed, or the individual with responsibility for managing the form filing process for the health maintenance organization with regard to the type of form filed; and (2) "improper certification" means providing any misrepresentation or false statement material to a certification form required pursuant to subsection a. of this section. L.1995,c.73,s.26.
N.J. Stat. § 26:2J-47 Annual assessment on HMOs.
3. a. (1) For the fiscal years 2005 and 2006, the Commissioner of Banking and Insurance shall issue, in accordance with the provisions of this section, a special interim assessment of one percent, and in fiscal year 2007 and each fiscal year thereafter through fiscal year 2019, an annual assessment in the amount of two percent, in fiscal year 2020, an annual assessment in the amount of three percent, in fiscal year 2021 and each fiscal year thereafter through fiscal year 2024, an annual assessment in the amount of five percent, and in fiscal year 2025 and each fiscal year thereafter, an annual assessment in the amount of six percent on the net written premiums received by each health maintenance organization granted a certificate of authority to operate in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.), to be allocated to the Health Care Subsidy Fund established pursuant to section 8 of P.L.1992, c.160 (C.26:2H-18.58) for the purpose of providing charity care payments to hospitals in accordance with the formula used for the distribution of charity care subsidies that are provided pursuant to P.L.1992, c.160 (C.26:2H-18.51 et al.). (2) "Net written premiums received" means direct premiums as reported on the annual financial statement submitted pursuant to section 9 of P.L.1973, c.337 (C.26:2J-9), and to the commissioner on a quarterly basis. b. The commissioner shall certify the amount of the annual assessment issued to each health maintenance organization as calculated pursuant to subsection a. of this section. Each health maintenance organization shall remit the amount so certified on a quarterly basis in each fiscal year to the Department of Banking and Insurance in accordance with the procedures established in P.L.1995, c.156 (C.17:1C-19 et seq.), and as prescribed by the commissioner, who may adjust the quarterly payments from time to time as necessary to meet the current and estimated assessment obligation of each health maintenance organization in each fiscal year. c. Amounts collected by the commissioner shall be allocated to the Health Care Subsidy Fund established pursuant to section 8 of P.L.1992, c.160 (C.26:2H-18.58) and used solely for the purpose of providing charity care payments to hospitals in accordance with the formula used for the distribution of charity care subsidies that are provided pursuant to P.L.1992, c.160 (C.26:2H-18.51 et al.). d. (1) A health maintenance organization shall not impose any additional premium, fee or surcharge on its premium or enrollee charge to recoup any assessment paid pursuant to this section. (2) The provisions of paragraph (1) of this subsection shall not apply to a health maintenance organization with respect to any federally funded program underwritten by that health maintenance organization. L.2004, c.49, s.3; amended 2005, c.129, s.2; 2006, c.43, s.1; 2019, c.148; 2020, c.96; 2024, c.21.
N.J. Stat. § 26:2J-48 Health maintenance organization, aggregate benefits.
5. a. Beginning with the calendar year starting on January 1, 2020, and in each calendar year thereafter, a health maintenance organization providing health benefits plans to a large employer shall return, in the form of aggregate benefits for all large group health benefits plans offered by the health maintenance organization, at least 85 percent of the aggregate premiums collected for all of those plans. b. A health maintenance organization shall annually report to the Commissioner of Banking and Insurance, no later than August 1 of each year, the loss ratio calculated for all health benefits plans for the previous calendar year. In each case in which the loss ratio fails to substantially comply with the 85 percent loss ratio requirement, the health maintenance organization shall issue a dividend or credit against future premiums for all contract holders in an amount sufficient to assure that the aggregate benefits paid in the previous calendar year plus the amount of the dividends and credits shall equal 85 percent of the premiums collected. The health maintenance organization shall distribute all dividends and credits by December 31 of the year following the calendar year in which the loss ratio requirements were not satisfied. The health maintenance organization's annual report shall include the health maintenance organization's calculation of the dividends and credits applicable to all health benefits plans, as well as an explanation of the health maintenance organization's plan to issue dividends or credits. c. The commissioner shall specify by regulation: (1) any informational filings required to be submitted by a health maintenance organization to the commissioner in order to determine whether the health maintenance organization is in compliance with the loss ratio requirements; (2) the instructions and format for calculating and reporting loss ratios and issuing dividends or credits; (3) procedures for the distribution of a dividend or credit in the event of cancellation or termination by a contract holder; and (4) the instructions and format for submitting annual reports. d. As used in this section, "large employer" means an employer with more than 50 employees, who is not a small employer as defined in section 1 of P.L.1992, c.162 (C.17B:27A-17). L.2019, c.358, s.5.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.njleg.state.nj.us/legislative-activity/statutesFetched: 10/17/2026