N.J. Stat. tit. 17B, ch. 27

in effect

N.J. Stat. § 17B:27-26 Definitions and requirements

Any policy or contract of health insurance which covers more than one person, other than a blanket insurance policy, or a policy issued pursuant to section 17B:26-2a(3), shall be deemed a group health insurance policy. No group health insurance policy may be delivered or issued for delivery in this State unless it conforms to one of the descriptions set forth in sections 17B:27-27 to 17B:27-29, inclusive. L.1971, c. 144, s. 17B:27-26.

N.J. Stat. § 17B:27-27 Employer, trustee, labor union, association groups

A policy issued to an employer or to the trustees of a fund established by one or more employers, or issued to a labor union, or issued to an association formed for purposes other than obtaining such insurance, or issued to the trustees of a fund established by one or more labor unions or by one or more employers and one or more labor unions, insuring employees and members of associations or labor unions. L.1971, c. 144, s. 17B:27-27.

N.J. Stat. § 17B:27-28 Other groups as permitted under group life insurance

Group health insurance may also be provided under a policy issued to cover such other groups as may be covered for group life insurance. L.1971, c. 144, s. 17B:27-28.

N.J. Stat. § 17B:27-29 Discretionary groups

A policy issued to insure any other group which, in the opinion of the commissioner, may be insured for group health insurance in accordance with sound underwriting principles. L.1971, c. 144, s. 17B:27-29.

N.J. Stat. § 17B:27-30 Dependents.

17B:27-30. Benefits of group health insurance, except benefits for loss of time on account of disability, may be provided for one or more members of the families or one or more dependents of persons who may be insured under a group policy referred to in section 17B:27-27, 17B:27-28 or 17B:27-29. Any group health insurance policy which contains provisions for the payment by the insurer of benefits for expenses incurred on account of hospital, nursing, medical, or surgical services for members of the family or dependents of a person in the insured group must, subject to payment of the appropriate premium, permit such family members or dependents to have coverage continued for at least 180 days after the death of the person in the insured group, subject to the policy provision as to termination of coverage with respect to family members or dependents for reasons other than the death of the person in the insured group. All group health insurance policies which provide coverage for a family member or dependent of an insured on an expense incurred basis shall also provide that the benefits applicable for children shall be payable with respect to a newly born child of that insured from the moment of birth. The coverage for newly born children shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. If payment of a specific premium is required to provide coverage for a child, the policy may require that notification of birth of a newly born child and payment of the required premium must be furnished to the insurer within 90 days after the date of birth in order to have the coverage continue beyond such 90-day period. All group health insurance policies which provide coverage on an expense incurred basis for the insured but do not provide coverage for a family member or dependent of the insured on an expense incurred basis, except such group policies as provide no dependent coverage whatsoever for the insured's class, shall nevertheless provide for coverage of newborn children of the insured which shall commence with the moment of birth of each child and shall consist of coverage of injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, provided application and payment of the required premium are made to the insurer to include in said policy coverage for a newly born child as described in the previous paragraph of this section within 90 days from the date of birth of a newborn child. A policy under which coverage of a dependent of an employee or other member of the insured group terminates at a specified age shall, with respect to an unmarried child covered by the policy prior to the attainment of age 19, who is incapable of self-sustaining employment by reason of intellectual disability or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon such employee or member for support and maintenance, not so terminate while the insurance of the employee or member remains in force and the dependent remains in such condition, if the insured employee or member has within 31 days of such dependent's attainment of the termination age submitted proof of such dependent's incapacity as described herein. The foregoing provision of this paragraph shall not require an insurer to insure a dependent who is a child with an intellectual disability or physical handicap of an employee or other member of the insured group where such dependent does not satisfy the conditions of the group policy as to any requirements for evidence of insurability or other provisions as may be stated in the group policy required for coverage thereunder to take effect. In any such case the terms of the policy shall apply with regard to the coverage or exclusion from coverage of such dependent. amended 1975, c.111, s.2; 1976, c.101, s.1; 2010, c.50, s.10; 2017, c.361, s.8; 2025, c.194, s.8.

N.J. Stat. § 17B:27-30.1 Benefits provided by group policy to subscriber's child.

11. a. A policy which provides hospital or medical expense benefits under 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 policy shall not deny coverage for an insured's child on the grounds that: (1) The child was born out of wedlock; (2) The child is not claimed as a dependent on the insured's federal tax return; (3) The child does not reside with the insured or in the insurer's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the policy 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 insurance policy of a noncustodial parent, the insurer shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits 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 covered 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 insured is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the insurer 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 under the health insurance policy if the parent who is the insured fails to enroll the child; and (3) Not terminate coverage of the child unless the parent who is the insured provides the insurer 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.11; amended 2019, c.356 s.4.

N.J. Stat. § 17B:27-30.2 Requirements applicable to State Medicaid

12. An insurer 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 insured. L.1995,c.288,s.12.

N.J. Stat. § 17B:27-30.3 Coverage provided by group health plan to subscriber's child.

15. a. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) which provides hospital or medical expense benefits under 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 plan shall not deny coverage for a covered employee's child on the grounds that: (1) The child was born out of wedlock; (2) The child is not claimed as a dependent on the covered employee's federal tax return; (3) The child does not reside with the covered employee or in the group health plan's service area, provided that, in the case of a managed care plan, the child complies with the terms and conditions of the plan 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 group health plan of a noncustodial parent, the plan shall: (1) Provide such information to the custodial parent as may be necessary for the child to obtain benefits 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 covered 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 covered employee is eligible for dependent coverage and is required by a court or administrative order to provide health insurance coverage for his child, the group health plan 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 under the group health plan if the parent who is the covered employee fails to enroll the child; and (3) Not terminate coverage of the child unless the parent who is the covered employee provides the group health plan 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.15; amended 2019, c.356 s.5.

N.J. Stat. § 17B:27-30.4 Requirements applicable to State Medicaid

16. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1) 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 covered employee. L.1995,c.288,s.16.

N.J. Stat. § 17B:27-30.5 Coverage for certain dependents until age 31 by group health insurance policy.

4. a. As used in this section, "dependent" means an insured'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 group health insurance policy that provides coverage for an insured's dependent under which coverage of the dependent terminates at a specific age on or before the dependent's 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this section of P.L.2008, c.38, shall, upon 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 policyholder 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 insured's policy, which coverage under the policy 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 policy; (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 policy previously terminated; or (c) during an open enrollment period, as provided pursuant to the policy, 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 policy. If coverage is modified under the policy for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the policy, 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 insured's policy may require payment of a premium by the insured 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 premium shall not exceed 102% of the applicable portion of the premium previously paid for that dependent's coverage under the policy prior to the termination of coverage at the specific age provided in the policy. (2) The applicable portion of the premium previously paid for the dependent's coverage under the policy shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the policy'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 of the premium 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 policy by reason of a failure to make a timely payment of any premium required under the policy by the insured or dependent for coverage provided pursuant to this section. The payment of any premium 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 policy; or (3) the date upon which the policy, under which coverage is provided to a dependent, ceases to provide coverage to the insured. Nothing herein shall be construed to permit an insurer 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 insured by the insurer: (1) in the certificate of coverage or other equivalent document prepared for insureds and delivered on or about the date of commencement of the insureds' coverage. (2) (Deleted by amendment, P.L.2008, c.38) h. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2005, c.375, s.4; amended 2008, c.38, s.32.

N.J. Stat. § 17B:27-31 "Employees" defined

The policy may provide that the term "employees" shall include as employees of a single employer the employees of one or more subsidiary corporations and the employees, individual proprietors and partners of affiliated corporations, proprietorships and partnerships if the business of the employer and such corporations, proprietorships or partnerships is under common control through stock ownership, contract or otherwise. The policy may provide that the term "employees" shall include the individual proprietor or partners of an individual proprietorship or a partnership. The policy may provide that the term "employees" shall include retired employees. A policy issued to trustees may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with such trusteeship. A policy issued to the trustees of a fund established by the members of an association of employers may provide that the term "employees" shall include the employees of the association. L.1971, c. 144, s. 17B:27-31.

N.J. Stat. § 17B:27-32 Blanket insurance

a. Any policy or contract of insurance against death or injury resulting from accident or from accidental means which conforms with the description and complies with the requirements contained in one of the following paragraphs shall be deemed a blanket insurance policy. (1) A policy or contract issued to any railroad, steamship, motor bus or airplane carrier of passengers, which carrier shall be deemed the policyholder, covering a group defined as all persons who may become such passengers and whereby such passengers shall be insured against loss or damage resulting from death or bodily injury either while, or as a result of, being such passengers. A policy or contract covering accidental death or injury to individuals resulting from airline accidents may also be issued under which premiums are paid from funds of the airline and the benefits are payable to the airline or to a trust established for the purpose of funding payments to persons with claims against the airline by reason of the death or bodily injury of individuals. (2) A policy or contract issued in the name of any volunteer fire department, first aid or ambulance squad or volunteer police organization which shall be deemed the policyholder and covering all of the members of any such organization against loss from accidents resulting from hazards incidental to duties in connection with such organizations. (3) A policy or contract issued in the name of any established organization, whether incorporated or not, having community recognition and operating for the welfare of the community and not for profit which shall be deemed the policyholder and covering all volunteer workers who are members of the organization and who serve without pecuniary compensation against loss from accidents occurring while engaged in the actual performance of duties on behalf of such organization. (4) A policy or contract issued to any employer, who shall be deemed the policyholder, covering any group of employees defined by reference to exceptional hazards incident to such employment, insuring such employees against death or bodily injury resulting while or from being exposed to such exceptional hazards. (5) A policy or contract issued to a college, school, or other institution of learning or to the head or principal thereof, who or which shall be deemed the policyholder. (6) A policy or contract issued to and in the name of an incorporated or unincorporated association of persons having a common interest or calling, which association shall be deemed the policyholder, having not less than 50 members, covering all the members of such association, or if part or all of the premium is to be derived from funds contributed by the insured members and if the opportunity to take such insurance is offered to all eligible members, then such policy must cover not less than 75% of any class or classes of members determined by conditions pertaining to membership in the association. (7) A policy or contract issued to insure any other substantially similar group approved by the commissioner as eligible for insurance under a blanket insurance policy or contract. b. Nothing contained in this section shall be deemed to affect the legal liability of policyholders for the death of or injury to any such member of such group. L.1971, c. 144, s. 17B:27-32.

N.J. Stat. § 17B:27-33 Standard provisions

No policy of group health or blanket insurance and no certificate thereunder shall be delivered or issued for delivery in this State unless the policy contains in substance all the provisions specified in sections 17B:27-34 to 17B:27-46 following. L.1971, c. 144, s. 17B:27-33.

N.J. Stat. § 17B:27-34 Application; statements

There shall be a provision that a copy of the application, if any, of the policyholder shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties, and that no statement made by any person insured shall avoid the insurance or reduce benefits thereunder unless contained in a written instrument signed by the person insured. L.1971, c. 144, s. 17B:27-34.

N.J. Stat. § 17B:27-35 Policy changes

There shall be a provision that no agent has authority to change the policy or to waive any of its provisions and that no change in the policy shall be valid unless approved by an officer of the insurer and evidenced by endorsement on the policy, or by amendment to the policy signed by the policyholder and the insurer. L.1971, c. 144, s. 17B:27-35.

N.J. Stat. § 17B:27-36 New entrants

There shall be a provision that all new employees or new members, as the case may be, in the groups or classes eligible for such insurance must be added to such eligible groups or classes. L.1971, c. 144, s. 17B:27-36.

N.J. Stat. § 17B:27-36.1 Eligibility for enrollment under policy providing hospital, medical expense benefits.

6. Notwithstanding any other provision of law to the contrary, an insurer shall not consider a person's eligibility for medical assistance pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the equivalent statute in another state, when determining the person's eligibility for enrollment in, or the provision of benefits under, a policy providing hospital or medical expense benefits delivered, issued or executed in this State, or approved for issuance in this State by the Commissioner of Insurance. L.1995,c.291,s.6.

N.J. Stat. § 17B:27-36.2 Group health insurance, policy, exclusion, rates, terms based on genetic information prohibited

15. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall 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.14.

N.J. Stat. § 17B:27-37 Payment of premiums

There shall be a provision that all premiums due under the policy shall be remitted by the employer or employers of the persons insured, by the policyholder, or by some other designated person acting on behalf of the association or group insured, to the insurer on or before the due date thereof with such period of grace as may be specified therein. L.1971, c. 144, s. 17B:27-37.

N.J. Stat. § 17B:27-38 Certificate

There shall be a provision that the insurer shall issue to the employer, the policyholder, or other person or association in whose name such policy is issued, for delivery to each employee or member, a certificate setting forth in summary form a statement of the essential features of the insurance coverage, to whom the benefits thereunder are payable, and in substance the provisions of sections 17B:27-39 to 17B:27-46, inclusive of this chapter. This section shall not apply to blanket policies issued pursuant to section 17B:27-32a(1) and 17B:27-32a(3) of this act, nor to group health policies insuring a private plan under the Temporary Disability Benefits Law, if reasonable notice of the benefits provided thereby is furnished to the covered employees by direct notification or by conspicuous posting at the place of employment. If family members or dependents are included in the coverage, only one certificate need be issued for each family unit. L.1971, c. 144, s. 17B:27-38.

N.J. Stat. § 17B:27-39 Age limits

There shall be a provision specifying the ages, if any there be, to which the insurance provided therein shall be limited; and the ages, if any there be, for which additional restrictions are placed on benefits, and the additional restrictions placed on the benefits at such ages. L.1971, c. 144, s. 17B:27-39.

N.J. Stat. § 17B:27-40 Notice of loss

There shall be a provision that written notice of sickness or of injury must be given to the insurer within 20 days after the date when such sickness or injury occurred. Failure to give notice within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to give such notice and that notice was given as soon as was reasonably possible. L.1971, c. 144, s. 17B:27-40.

N.J. Stat. § 17B:27-41 Proof of loss

There shall be a provision that in the case of claim for loss of time for disability, written proof of such loss must be furnished to the insurer within 30 days after the commencement of the period for which the insurer is liable, and that subsequent written proofs of the continuance of such disability must be furnished to the insurer at such intervals as the insurer may reasonably require, and that in the case of claim for any other loss, written proof of such loss must be furnished to the insurer within 90 days after the date of such loss. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it shall be shown not to have been reasonably possible to furnish such proof and that such proof was furnished as soon as was reasonably possible. L.1971, c. 144, s. 17B:27-41.

N.J. Stat. § 17B:27-42 Forms for proof

There shall be a provision that the insurer will furnish to the person making claim, or to the policyholder for delivery to such person, such forms as are usually furnished by it for filing proof of loss. If the person making claim does not receive such forms before the expiration of 15 days after the insurer receives notice of any claim under the policy, the person making such claim shall be deemed to have complied with the requirements of the policy as to proof of loss upon submitting within the time fixed in the policy for filing proof of loss, written proof covering the occurrence, character and extent of the loss for which claim is made. L.1971, c. 144, s. 17B:27-42.

N.J. Stat. § 17B:27-43 Examination, autopsy

There shall be a provision that the insurer shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of claim under the policy and also the right and opportunity to make an autopsy in case of death where it is not prohibited by law. L.1971, c. 144, s. 17B:27-43.

N.J. Stat. § 17B:27-44 Time of benefit payment

There shall be a provision that all benefits payable under the policy other than benefits for loss of time will be payable not more than 60 days after receipt of proof, and that, subject to due proof of loss, all accrued benefits payable under the policy for loss of time will be paid not later than at the expiration of each period of 30 days during the continuance of the period for which the insurer is liable, and that any balance remaining unpaid at the termination of such period will be paid immediately upon receipt of such proof. L.1971, c. 144, s. 17B:27-44.

N.J. Stat. § 17B:27-44.2 Health insurer to receive, transmit transactions relative to group policies electronically; standards.

6. 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 insurer 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 insurer, 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 insurer 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 policies 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 insurer 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 policy. 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 insurer 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 insurer 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 policy for which the financial obligation for the payment of a claim under the policy rests upon the health insurer. 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.6; amended 2005, c.352, s.14; 2023, c.296, s.23.

N.J. Stat. § 17B:27-45 Beneficiary; direct payment to hospitals and other purveyors of services

There shall be a provision that indemnity for loss of life of the insured shall be payable to the beneficiary or beneficiaries designated by the insured, other than the policyholder or an officer thereof as such, or if no beneficiary is designated, to such other person or persons as shall be specified in the policy; and that all other indemnities of the policy are payable to the employee or member, except that, at the request of the employee or member or in the event of his death, payment of benefits to the extent of expenses incurred on account of hospitalization may be made by the insurer to the hospital and except that the group policy may provide that all or any portion of any benefits on account of hospital, nursing, medical or surgical services may, at the insurer's option, be paid directly to the hospital or person rendering such services provided, further, that authorization for any such payments has been obtained from the insured. If a beneficiary is designated, the consent of the beneficiary shall not be requisite to change of beneficiary or to any other changes in the policy or certificate except as may be specifically provided by the policy. This section shall not apply to a blanket insurance policy issued to an airline under which the benefits are payable to the airline or a trust established by the airline and the premiums are paid from its funds. L.1971, c. 144, s. 17B:27-45.

N.J. Stat. § 17B:27-46 Time limits, suits

There shall be a provision that no action at law or in equity shall be brought to recover on the policy prior to the expiration of 60 days after proof of loss has been filed in accordance with the requirements of the policy and that no such action shall be brought at all unless brought within 3 years from the expiration of the time within which proof of loss is required by the policy. L.1971, c. 144, s. 17B:27-46.

N.J. Stat. § 17B:27-46.1a Reconstructive breast surgery; benefits

1. Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits, following a mastectomy on one breast or both breasts, for reconstructive breast surgery, surgery to restore and achieve symmetry between the two breasts, and the costs of prostheses and, under any policy providing outpatient x-ray or radiation therapy, the costs of 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 coverage. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. Such benefits shall be provided to the same extent as for any other sickness under the policy. L.1983,c.52,s.1; amended 1997, c.75, s.5.

N.J. Stat. § 17B:27-46.1aa Policy issued under Chapter 27 of Title 17B required to cover certain out-of-network services.

4. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy meets the requirements of P.L.2001, c.367 (C.26:2S-6.1 et al.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2001,c.367,s.4.

N.J. Stat. § 17B:27-46.1aaa Benefits provided under group health policies.

5. a. Every group health policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2025, c.200 (C. 17:48-6bbb et al.), shall provide benefits to any named insured or other person covered thereunder for expenses incurred in obtaining medically necessary treatment for women with a diagnosis of perimenopause, menopause, and symptoms associated with perimenopause and menopause, including, but not limited to: (1) hormonal therapies such as hormone replacement therapy and bioidentical hormone treatments; (2) non-hormonal treatments, including medications to manage perimenopause and menopausal symptoms; (3) behavioral health care services; (4) pelvic floor physical therapy; (5) bone health treatments, including screenings and medications due to hormonal changes related to perimenopause and menopause; (6) preventative services that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force for early detection and treatment of health conditions related to perimenopause and menopause such as osteoporosis and cancer; and (7) counseling and education regarding menopause management. b. Every group policy shall provide clear and accessible information to insureds regarding covered perimenopause and menopause treatments. c. The benefits shall be provided to the same extent as for any other medical condition under the policy. d. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. e. As used in this section: “Menopause” means the permanent end of a female’s menstrual cycle, diagnosed by a licensed medical provider after 12 consecutive months without a menstrual period. “Perimenopause” means the transitional period leading to menopause, marked by fluctuating hormone levels and changes in menstrual cycles. L.2025, c.200, s.5.

N.J. Stat. § 17B:27-46.1b Group health insurance policies

Every group health insurance policy providing hospital or medical expense benefits delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this amendatory and supplementary act, shall offer coverage for maternity care without regard to marital status to subscribers or other persons covered thereunder for expenses incurred in pregnancy and childbirth. The benefits for the expenses of pregnancy and childbirth shall be provided to the same extent as the hospitalization benefit is provided in the policy for any other covered illness. If a fixed amount is specified in the policy for surgery, the fixed amount for a pregnancy-related surgical procedure shall be commensurate with the fixed amount payable for a surgical procedure of comparable difficulty and severity. L. 1985, c. 277, s. 2.

N.J. Stat. § 17B:27-46.1bb Group health insurer to offer coverage for domestic partner.

51. A group health insurer that provides hospital or medical expense benefits under a policy that is delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2003, c.246 (C.26:8A-1 et al.), under which dependent coverage is available, shall offer dependent coverage to a covered person for a covered person's domestic partner. For the purposes of this section, "domestic partner" means a domestic partner as defined in section 3 of P.L.2003, c.246 (C.26:8A-3). This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2003,c.246,s.51.

N.J. Stat. § 17B:27-46.1c Benefits for purchase of blood products, infusion equipment

Every group health insurance policy providing hospital expense benefits to any policy holder or other person covered thereunder for expenses incurred in connection with the treatment of routine bleeding episodes associated with hemophilia shall provide benefits for expenses incurred in connection with the purchase of blood products and blood infusion equipment required for home treatment of routine bleeding episodes associated with hemophilia when the home treatment program is under the supervision of a State approved hemophilia treatment center. The benefits shall be provided to the same extent as for any sickness under the policy. As used in this act, "blood product" includes, but is not limited to, Factor VIII, Factor IX and cryoprecipitate; and "blood infusion equipment" includes, but is not limited to, syringes and needles. Participation in a home treatment program shall not preclude further or additional treatment or care at any eligible facility if the number of home treatments, in accordance with a ratio of home treatments to benefit days established by regulation by the Commissioner of Insurance, does not exceed the total number of benefit days provided for any other sickness under the policy. L. 1987, c. 63, s. 1.

N.J. Stat. § 17B:27-46.1cc Group health insurance policy, high deductible, coverage for preventive care.

8. No group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons, that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in connection with any medically necessary benefits provided in-network which represent preventive care as permitted by that federal law. The benefits provided pursuant to this section shall be provided to the same extent as for any other medical condition under the policy, except that a deductible shall not be applied for benefits provided pursuant to this section. This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium. L.2005,c.248,s.8.

N.J. Stat. § 17B:27-46.1d Commercial health insurer benefits for preexisting condition

a. Notwithstanding any other provision of law to the contrary, no group health insurance policy issued by an insurer pursuant to the provisions of Chapter 27 of Title 17B of the New Jersey Statutes, shall contain any provision which denies benefits for a preexisting condition to any person becoming a member of that group if: (1) during the period immediately preceding the person's becoming a member of the group the person was enrolled as a member under another group policy issued by the insurer; and (2) the insurer paid benefits for the condition under the group policy in which the person was previously insured. b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any group policy. c. This section shall apply to every group contract or policy in which the corporation or insurer has the right to change the premium. L.1989, c.63, s.4.

N.J. Stat. § 17B:27-46.1dd Group health insurance policy, high deductible, deductible inapplicable, certain circumstances.

9. Notwithstanding the provisions of section 3 of P.L.1995, c.316 (C.17B:27-46.1l) regarding deductibles for a high deductible health plan, a group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons, that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), shall not apply a deductible for any benefits for which a deductible is not applicable pursuant to any law enacted after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.). This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium. L.2005,c.248,s.9.

N.J. Stat. § 17B:27-46.1e Group health insurance policy to pay benefits for treatment of Wilm's tumor

Every group health insurance policy providing hospital or medical expense benefits shall provide benefits to any named insured or other person covered thereunder for expenses incurred in the treatment of Wilm's tumor, including autologous bone marrow transplants when standard chemotherapy treatment is unsuccessful, notwithstanding that any such treatment may be deemed experimental or investigational. These benefits shall be provided to the same extent as for any other sickness under the policy. L.1990,c.71,s.5.

N.J. Stat. § 17B:27-46.1ee Group health insurers, coverage for contraceptives.

4. a. A group health insurer that provides hospital or medical expense benefits shall provide coverage under every policy delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis: (1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions: (a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product. (b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. (c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration. (2) Voluntary male and female sterilization. (3) Patient education and counseling on contraception. (4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to: (a) Management of side effects; (b) Counseling for continued adherence to a prescribed regimen; (c) Device insertion and removal; (d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and (e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section. b. The coverage provided shall include prescriptions for dispensing contraceptives for: (1) (Deleted by amendment, P.L.2021, c.376) (2) up to a 12-month period at one time. c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the policy, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed. (2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). d. This section shall apply to those policies in which the insurer has reserved the right to change the premium. e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13. L.2005, c.251, s.4; amended 2017, c.241, s.4; 2019, c.361, s.4; 2021, c.376, s.4.

N.J. Stat. § 17B:27-46.1f Group health insurance policy, mammogram examination benefits.

5. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting: (1) one baseline mammogram examination for women who are 40 years of age; a mammogram examination every year for women age 40 and over; and, in the case of a woman who is under 40 years of age and has a family history of breast cancer or other breast cancer risk factors, a mammogram examination at such age and intervals as deemed medically necessary by the woman's health care provider; and (2) an ultrasound evaluation, a magnetic resonance imaging scan, a three-dimensional mammography, or other additional testing of an entire breast or breasts, after a baseline mammogram examination, if the mammogram demonstrates extremely dense breast tissue, if the mammogram is abnormal within any degree of breast density including not dense, moderately dense, heterogeneously dense, or extremely dense breast tissue, or if the patient has additional risk factors for breast cancer including but not limited to family history of breast cancer, prior personal history of breast cancer, positive genetic testing, extremely dense breast tissue based on the Breast Imaging Reporting and Data System established by the American College of Radiology, or other indications as determined by the patient's health care provider. The coverage required under this paragraph may be subject to utilization review, including periodic review, by the insurer of the medical necessity of the additional screening and diagnostic testing. b. These benefits shall be provided to the same extent as for any other sickness under the policy. c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.1991, c.279, s.5; amended 1999, c.341, s.5; 2004, c.86, s.5; 2013, c.196, s.5.

N.J. Stat. § 17B:27-46.1ff Group health insurance policies to provide benefits for orthotic and prosthetic appliances.

5. a. Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), shall provide benefits to any person covered thereunder for expenses incurred in obtaining: (1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and (2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, licensed podiatrist, or any certified pedorthist, if the covered person's physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports. As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3), "licensed podiatrist" has the meaning assigned to it in R.S.45:5-1 et seq., and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18). b. On and after the effective date of P.L.2007, c.345 (C.17:48-6ff et al.), a group health insurance policy shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule. c. The benefits shall be provided to the same extent as for any other medical condition under the policy. d. The provisions of this section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. L.2007, c.345, s.5; amended 2025, c.89, s.5.

N.J. Stat. § 17B:27-46.1g .Group health insurance policy, benefits for "off-label" drugs required

6. a. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy which provides benefits for expenses incurred in prescribing drugs approved by the federal Food and Drug Administration shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State, on or after the effective date of this act unless the policy provides benefits to any policyholder or other person covered thereunder for expenses incurred in prescribing a drug for a treatment for which it has not been approved by the Food and Drug Administration if the drug is recognized as being medically appropriate for the specific treatment for which 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. The benefits provided pursuant to this section shall be provided to the same extent as other benefits under the policy for drugs prescribed for treatments approved by the Food and Drug Administration. c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. d. Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug. L.1993,c.321,s.6.

N.J. Stat. § 17B:27-46.1gg Group health insurance policy to provide coverage for hearing aids, cochlear implant for covered persons.

6. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medically necessary expenses incurred in the purchase of a hearing aid or cochlear implant for a covered person, as provided in this section. b. A policy shall provide coverage that includes the purchase of a hearing aid for each ear, when medically necessary and as prescribed or recommended by a licensed physician or audiologist. An insurer may limit the benefit provided in this section to one hearing aid for each hearing-impaired ear every 24 months. c. A group health insurance policy shall provide coverage of the cost of treatment related to cochlear implants, including procedures for the implantation of cochlear devices and costs for any parts, attachments, or accessories of the device, including replacement of obsolete external cochlear implant processors. d. The benefits shall be provided to the same extent as for any other condition under the policy. e. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2008, c.126, s.6; amended 2023, c.275, s.5.

N.J. Stat. § 17B:27-46.1h Group health insurer, benefits for health promotion

7. a. Every group policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.1999, c.339, shall provide benefits to each person covered thereunder for expenses incurred in a health promotion program through health wellness examinations and counselling, which program shall include, but not be limited to, the following tests and services: (1) For all persons 20 years of age and older, annual tests to determine blood hemoglobin, blood pressure, blood glucose level, and blood cholesterol level or, alternatively, low-density lipoprotein (LDL) level and blood high-density lipoprotein (HDL) level; (2) For all persons 35 years of age or older, a glaucoma eye test every five years; (3) For all persons 40 years of age or older, an annual stool examination for presence of blood; (4) For all persons 45 years of age or older, a left-sided colon examination of 35 to 60 centimeters every five years; (5) For all women 20 years of age or older, a pap smear pursuant to the provisions of section 4 of P.L.1995, c.415 (C.17B:27-46.1n); (6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 5 of P.L.1991, c.279 (C.17B:27-46.1f); (7) For all adults, recommended immunizations; and (8) For all persons 20 years of age or older, an annual consultation with a health care provider to discuss lifestyle behaviors that promote health and well-being including, but not limited to, smoking control, nutrition and diet recommendations, exercise plans, lower back protection, weight control, immunization practices, breast self-examination, testicular self-examination and seat belt usage in motor vehicles. Notwithstanding the provisions of this subsection to the contrary, if a physician or other health care provider recommends that it would be medically appropriate for a covered person to receive a different schedule of tests and services than that provided for under this subsection, the insurer shall provide payment for the tests or services actually provided, within the limits of the amounts listed in subsection b. of this section. b. Every group health care policy offered for sale in this State by an insurer pursuant to subsection a. of this section shall provide payment for the benefits set forth in subsection a. in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no insurer shall be required to provide payment for benefits for a left-sided colon examination in excess of $150. c. The Commissioner of Banking and Insurance, in consultation with the Department of the Treasury, shall annually adjust the threshold amounts provided by subsection b. of this section in direct proportion to the increase or decrease in the consumer price index for all urban consumers in the New York City and Philadelphia areas as reported by the United States Department of Labor. The adjustment shall become effective on July 1 of the year in which the adjustment is made. d. The requirements of this section shall apply only to health insurers which issue or deliver primary health insurance coverage in this State providing hospital or medical expense benefits. Primary health insurance coverage shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, Medicare supplement coverage, CHAMPUS supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, coverage for Medicaid services pursuant to a contract with the State, coverage arising out of a workers' compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage. e. This section shall apply to all group health insurance policies in which the carrier has reserved the right to change the premium. 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.7; amended 1999, c.339, s.5.

N.J. Stat. § 17B:27-46.1hh Group health insurance policy to provide installment payments to obstetrical provider for maternity services.

5. a. Every group health insurance policy that provides benefits for maternity services, and that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide for reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a covered person's pregnancy. b. For the purposes of this section, "obstetrical provider licensed in New Jersey" means: (1) an obstetrician/gynecologist licensed by the State Board of Medical Examiners; or (2) a midwife licensed by the State Board of Medical Examiners as a certified midwife or a certified nurse midwife. c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. L.2009, c.113, s.5.

N.J. Stat. § 17B:27-46.1i Requirements for group health insurer providing benefits for pharmacy services.

5. a. Notwithstanding any other provision of law to the contrary, no group health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State, on or after the effective date of this act, unless the policy: (1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist for the provision of prescription drugs or pharmacy services, provided that any pharmacist or pharmacy selected by the insured 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 policy 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 policy; (3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy; (4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy; (b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and (c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days; (5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer; (6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law; (7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395. b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy. c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. L.1993,c.378,s.5; amended 1999, c.395, s.5.

N.J. Stat. § 17B:27-46.1ii Group health insurance policy to provide benefits for treatment of autism or other developmental disability.

5. Notwithstanding any other provision of law to the contrary, every group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage pursuant to the provisions of this section. a. The insurer shall provide coverage for expenses incurred in screening and diagnosing autism or another developmental disability. b. When the insured's primary diagnosis is autism or another developmental disability, the insurer shall provide coverage for expenses incurred for medically necessary occupational therapy, physical therapy, and speech therapy, as prescribed through a treatment plan. Coverage of these therapies shall not be denied on the basis that the treatment is not restorative. c. When the insured is under 21 years of age and the insured's primary diagnosis is autism, the insurer shall provide coverage for expenses incurred for medically necessary behavioral interventions based on the principles of applied behavioral analysis and related structured behavioral programs, as prescribed through a treatment plan, subject to the provisions of this subsection. (1) Except as provided in paragraph (3) of this subsection, the benefits provided pursuant to this subsection shall be provided to the same extent as for any other medical condition under the policy, but shall not be subject to limits on the number of visits that an insured may make to a provider of behavioral interventions. (2) The benefits provided pursuant to this subsection shall not be denied on the basis that the treatment is not restorative. (3) (a) The maximum benefit amount for an insured in any calendar year through 2011 shall be $36,000. (b) Commencing on January 1, 2012, the maximum benefit amount shall be subject to an adjustment, to be promulgated by the Commissioner of Banking and Insurance and published in the New Jersey Register no later than February 1 of each calendar year, which shall be equal to the change in the consumer price index for all urban consumers for the nation, as prepared by the United States Department of Labor, for the calendar year preceding the calendar year in which the adjustment to the maximum benefit amount is promulgated. (c) The adjusted maximum benefit amount shall apply to a policy that is delivered, issued, executed, or renewed, or approved for issuance or renewal, in the 12-month period following the date on which the adjustment is promulgated. (d) Notwithstanding the provisions of this paragraph to the contrary, an insurer shall not be precluded from providing a benefit amount for an insured in any calendar year that exceeds the benefit amounts set forth in subparagraphs (a) and (b) of this paragraph. d. The treatment plan required pursuant to subsections b. and c. of this section shall include all elements necessary for the insurer to appropriately provide benefits, including, but not limited to: a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician's signature. The insurer may only request an updated treatment plan once every six months from the treating physician to review medical necessity, unless the insurer and the treating physician agree that a more frequent review is necessary due to emerging clinical circumstances. e. The provisions of subsections b. and c. of this section shall not be construed as limiting benefits otherwise available to an insured. f. The provisions of subsections b. and c. of this section shall not be construed to require that benefits be provided to reimburse the cost of services provided under an individualized family service plan or an individualized education program, or affect any requirement to provide those services; except that the benefits provided pursuant to those subsections shall include coverage for expenses incurred by participants in an individualized family service plan through a family cost share. g. The coverage required under this section may be subject to utilization review, including periodic review, by the insurer of the continued medical necessity of the specified therapies and interventions. h. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2009, c.115, s.5.

N.J. Stat. § 17B:27-46.1j Benefits for certain cancer treatments

5. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), an insurer shall offer under every group policy providing health insurance coverage delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act to provide benefits for the treatment of cancer by dose-intensive chemotherapy/autologous bone marrow transplants and peripheral blood stem cell transplants when performed by institutions approved by the National Cancer Institute or pursuant to protocols consistent with the guidelines of the American Society of Clinical Oncologists. Benefits for such treatment shall be provided to the same extent as for any other illness under the policy. The offer required pursuant to this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium. Nothing in this section shall be construed to limit an insurer in adjusting premium amounts, or providing for reasonable deductibles or copayments, with respect to benefits provided pursuant to this section. L.1995,c.100,s.5.

N.J. Stat. § 17B:27-46.1jj Group health insurance policy to provide coverage for oral anticancer medications.

5. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells on a basis no less favorable than the policy provides for intravenously administered or injected anticancer medications. b. Pursuant to subsection a. of this section, coverage for expenses for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells shall not be subject to any prior authorization, dollar limit, copayment, deductible or coinsurance provision that does not apply to intravenously administered or injected anticancer medications. c. A group health insurance policy shall not achieve compliance with the provisions of this section by imposing an increase in patient cost sharing, including any copayment, deductible or coinsurance, for anticancer medications, whether intravenously administered or injected or orally administered, that are covered under the policy as of the effective date of this act. d. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2011, c.188, s.5.

N.J. Stat. § 17B:27-46.1k Coverage for birth and natal care; group insurance policy

7. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 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 benefits for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. b. Notwithstanding the provisions of subsection a. of this section, a policy that provides coverage for post-delivery care to a mother and her newly born child in the home shall not be required to provide for a minimum of 48 hours and 96 hours, respectively, of in-patient care unless such in-patient care is determined to be medically necessary by the attending physician or is requested by the mother. For the purposes of this section, attending physician shall include the attending obstetrician, pediatrician or other physician attending the mother or newly born child. c. Every insurer shall provide notice to policyholders regarding the coverage required by this section in accordance with this subsection and regulations promulgated by the Commissioner of Health pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). The notice shall be in writing and prominently positioned in any literature or correspondence and shall be transmitted at the earliest of: (1) the next mailing to the policyholder; (2) the yearly informational packet sent to the policyholder; or (3) January 1, 1996. L.1995,c.138,s.7.

N.J. Stat. § 17B:27-46.1kk Group health insurance policy to provide coverage for sickle cell anemia.

4. Every group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for medical expenses incurred by a covered person for the treatment of sickle cell anemia and, if the policy provides benefits for expenses incurred in the purchase of outpatient prescription drugs, then the policy shall provide coverage for prescription drug expenses incurred by a covered person for the treatment of sickle cell anemia. The benefits shall be provided to the same extent as for any other medical condition under the policy. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2011, c.210, s.4.

N.J. Stat. § 17B:27-46.1l Group health insurance policy, child screening, blood lead, hearing loss; immunizations.

3. No group health insurance policy providing hospital or medical expense benefits for groups with more than 50 persons shall be delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in the following: a. Screening by blood lead measurement for lead poisoning for children, including confirmatory blood lead testing as specified by the Department of Health pursuant to section 7 of P.L.1995, c.316 (C.26:2-137.1); and medical evaluation and any necessary medical follow-up and treatment for lead poisoned children. b. All childhood immunizations as recommended by the 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 insurer shall notify its policyholders, in writing, of any change in coverage with respect to childhood immunizations and any related changes in premium. Such notification shall be in a form and manner to be determined by the Commissioner of Banking and Insurance. c. Screening for newborn hearing loss by appropriate electrophysiologic screening measures and periodic monitoring of infants for delayed onset hearing loss, pursuant to P.L.2001, c.373 (C.26:2-103.1 et al.). Payment for this screening service shall be separate and distinct from payment for routine new baby care in the form of a newborn hearing screening fee as negotiated with the provider and facility. The benefits provided pursuant to this section shall be provided to the same extent as for any other medical condition under the policy, except that a deductible shall not be applied for benefits provided pursuant to this section; however, with respect to a policy that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), a deductible shall not be applied for any benefits provided pursuant to this section that represent preventive care as permitted by that federal law, and shall not be applied as provided pursuant to section 9 of P.L.2005, c.248 (C.17B:27-46.1dd). This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium. L.1995, c.316, s.3; amended 2001, c.373, s.12; 2005, c.248, s.7; 2012, c.17, s.55; 2025, c.283, s.8.

N.J. Stat. § 17B:27-46.1ll Group health insurer to provide coverage for prescription eye drops.

5. a. A group health insurer which provides hospital or medical expense benefits that include coverage for prescription eye drops, under a policy delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for refills of prescription eye drops in accordance with the Guidance for Early Refill Edits of Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare & Medicaid Services of the U.S. Department of Health and Human Services, provided that: (1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and (2) the refill requested by the insured or covered person does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner. b. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2013, c.50, s.5.

N.J. Stat. § 17B:27-46.1m Coverage, diabetes treatment, group health insurance policy.

5. a. Every group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits to any person covered thereunder for expenses incurred for the following equipment and supplies for the treatment of diabetes, if recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist: blood glucose monitors and blood glucose monitors for the legally blind; test strips for glucose monitors and visual reading and urine testing strips; insulin; injection aids; cartridges for the legally blind; syringes; insulin pumps and appurtenances thereto; insulin infusion devices; and oral agents for controlling blood sugar. Coverage for the purchase of a short-acting, intermediate-acting, rapid-acting, long-acting, and pre-mixed insulin product shall not be subject to any deductible, and no copayment or coinsurance for the purchase of insulin shall exceed $35 per 30-day supply. The provisions of this subsection shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this subsection shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this subsection shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. b. Each group health insurance policy shall also provide benefits for expenses incurred for diabetes self-management education to ensure that a person with diabetes is educated as to the proper self-management and treatment of their diabetic condition, including information on proper diet. Benefits provided for self-management education and education relating to diet shall be limited to visits medically necessary upon the diagnosis of diabetes; upon diagnosis by a physician or nurse practitioner/clinical nurse specialist of a significant change in the covered person's symptoms or conditions which necessitate changes in that person's self-management; and upon determination of a physician or nurse practitioner/clinical nurse specialist that reeducation or refresher education is necessary. Diabetes self-management education shall be provided by a dietitian registered by a nationally recognized professional association of dietitians or a health care professional recognized as a Certified Diabetes Educator by the American Association of Diabetes Educators or a registered pharmacist in the State qualified with regard to management education for diabetes by any institution recognized by the board of pharmacy of the State of New Jersey. c. The benefits required by this section shall be provided to the same extent as for any other sickness under the policy. d. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. e. The provisions of this section shall not apply to a health benefits plan subject to the provisions of P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.). f. The Commissioner of Banking and Insurance may, in consultation with the Commissioner of Health, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), promulgate and periodically update a list of additional diabetes equipment and related supplies that are medically necessary for the treatment of diabetes and for which benefits shall be provided according to the provisions of this section. L.1995, c.331, s.5; amended 2023, c.105, s.13.

N.J. Stat. § 17B:27-46.1mm Group health insurance policy, contract, coverage for synchronization of prescribed medications.

5. a. Every group health insurance policy or contract delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State on or after the effective date of this act, which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall, on at least one occasion per year for each covered person: (1) apply a prorated daily cost-sharing rate to prescriptions that are dispensed by a network pharmacy for less than a 30 days' supply if the prescriber or pharmacist indicates the fill or refill is in the best interest of the covered person or is for the purpose of synchronizing the covered person's chronic medications; (2) provide coverage for a drug prescribed for the treatment of a chronic illness dispensed in accordance with a plan among the covered person, the prescriber and the pharmacist to synchronize the refilling of multiple prescriptions for the covered person; and (3) determine dispensing fees based exclusively on the total number of prescriptions dispensed; dispensing fees shall not be prorated or based on the number of the days' supply of medication prescribed or dispensed. b. This section shall apply to all policies in which the insurer has reserved the right to change the premium. c. This section shall not apply to prescriptions for opioid analgesics. "Opioid analgesic" means a drug in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions, whether in immediate release or extended release form, and whether or not combined with other drug substances to form a single drug product or dosage form. L.2015, c.206, s.5.

N.J. Stat. § 17B:27-46.1n Group health insurance policy, Pap smear benefits

4. No group health insurance policy providing hospital or medical expense benefits for groups with greater than 50 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting a Pap smear. The benefits shall be provided to the same extent as for any other medical condition under the policy. As used in this section, and notwithstanding the provisions of this section to the contrary, "Pap smear" means an initial Pap smear and any confirmatory test when medically necessary and as ordered by the covered person's physician and includes all laboratory costs associated with the initial Pap smear and any such confirmatory test. This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium. L.1995, c.415, s.4; amended 2001, c.227, s.4.

N.J. Stat. § 17B:27-46.1nn Group health insurance to provide benefits for treatment of substance use disorder.

5. a. A group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide unlimited benefits for inpatient and outpatient treatment of substance use disorder at in-network facilities. The services for the treatment of substance use disorder shall be prescribed by a licensed physician, licensed psychologist, or licensed psychiatrist and provided by licensed health care professionals or licensed or certified substance use disorder providers in licensed or otherwise State-approved facilities, as required by the laws of the state in which the services are rendered. b. The benefits for the first 180 days per plan year of inpatient and outpatient treatment of substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. The facility shall notify the insurer of both the admission and the initial treatment plan within 48 hours of the admission or initiation of treatment. If there is no in-network facility immediately available for a covered person, an insurer shall provide necessary exceptions to its network to ensure admission in a treatment facility within 24 hours. c. Providers of treatment for substance use disorder to persons covered under a covered insurance policy shall not require pre-payment of medical expenses during this 180 days in excess of applicable co-payment, deductible, or co-insurance under the policy. d. The benefits for outpatient visits shall not be subject to concurrent or retrospective review of medical necessity or any other utilization management review. e. (1) The benefits for the first 28 days of an inpatient stay during each plan year shall be provided without any retrospective review or concurrent review of medical necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of inpatient care shall be subject to concurrent review as defined in this section. A request for approval of inpatient care beyond the first 28 days shall be submitted for concurrent review before the expiration of the initial 28-day period. A request for approval of inpatient care beyond any period that is approved under concurrent review shall be submitted within the period that was previously approved. No insurer shall initiate concurrent review more frequently than at two-week intervals. If an insurer determines that continued inpatient care in a facility is no longer medically necessary, the insurer shall within 24 hours provide written notice to the covered person and the covered person's physician of its decision and the right to file an expedited internal appeal of the determination pursuant to an expedited process pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.5, as applicable. The insurer shall review and make a determination with respect to the internal appeal within 24 hours and communicate such determination to the covered person and the covered person's physician. If the determination is to uphold the denial, the covered person and the covered person's physician have the right to file an expedited external appeal with the Independent Health Care Appeals Program in the Department of Banking and Insurance pursuant to sections 11 through 13 of P.L.1997, c.192 (C.26:2S-11 through 26:2S-13) and N.J.A.C.11:24A-3.6, as applicable. An independent utilization review organization shall make a determination within 24 hours. If the insurer's determination is upheld and it is determined continued inpatient care is not medically necessary, the insurer shall remain responsible to provide benefits for the inpatient care through the day following the date the determination is made and the covered person shall only be responsible for any applicable co-payment, deductible and co-insurance for the stay through that date as applicable under the policy. The covered person shall not be discharged or released from the inpatient facility until all internal appeals and independent utilization review organization appeals are exhausted. For any costs incurred after the day following the date of determination until the day of discharge, the covered person shall only be responsible for any applicable cost-sharing, and any additional charges shall be paid by the facility or provider. f. (1) The benefits for the first 28 days of intensive outpatient or partial hospitalization services shall be provided without any retrospective review of medical necessity and medical necessity shall be as determined by the covered person's physician. (2) The benefits for days 29 and thereafter of intensive outpatient or partial hospitalization services shall be subject to a retrospective review of the medical necessity of the services. g. Benefits for inpatient and outpatient treatment of substance use disorder after the first 180 days per plan year shall be subject to the medical necessity determination of the insurer and may be subject to prior authorization or, retrospective review and other utilization management requirements. h. Medical necessity review shall utilize an evidence-based and peer reviewed clinical review tool to be designated through rulemaking by the Commissioner of Human Services in consultation with the Department of Health. i. The benefits for outpatient prescription drugs to treat substance use disorder shall be provided when determined medically necessary by the covered person's physician, psychologist or psychiatrist without the imposition of any prior authorization or other prospective utilization management requirements. j. The first 180 days per plan year of benefits shall be computed based on inpatient days. One or more unused inpatient days may be exchanged for two outpatient visits. All extended outpatient services such as partial hospitalization and intensive outpatient, shall be deemed inpatient days for the purpose of the visit to day exchange provided in this subsection. k. Except as stated above, the benefits and cost-sharing shall be provided to the same extent as for any other medical condition covered under the policy. l. The benefits required by this section are to be provided to all covered persons with a diagnosis of substance use disorder. The presence of additional related or unrelated diagnoses shall not be a basis to reduce or deny the benefits required by this section. m. The provisions of this section shall apply to those policies in which the insurer has reserved the right to change the premium. n. The Attorney General's Office shall be responsible for overseeing any violations of law that may result from P.L.2017, c.28 (C.17:48-6nn et al.), including fraud, abuse, waste, and mistreatment of covered persons. The Attorney General's Office is authorized to adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations to implement any of the provisions of P.L.2017, c.28 (C.17:48-6nn et al.). o. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the "Family Health Care Coverage Act," P.L.2005, c.156 (C.30:4J-8 et seq.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services. p. As used in this section: "Concurrent review" means inpatient care is reviewed as it is provided. Medically qualified reviewers monitor appropriateness of the care, the setting, and patient progress, and as appropriate, the discharge plans. "Substance use disorder" is as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and any subsequent editions and shall include substance use withdrawal. L.2017, c.28, s.5.

N.J. Stat. § 17B:27-46.1o Group health insurance policy, prostate cancer testing

4. No group health insurance policy providing hospital or medical expense benefits for groups with greater than 49 persons shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting an annual medically recognized diagnostic examination including, but not limited to, a digital rectal examination and a prostate-specific antigen test for men age 50 and over who are asymptomatic and for men age 40 and over with a family history of prostate cancer or other prostate cancer risk factors. The benefits shall be provided to the same extent as for any other medical condition under the policy. This section shall apply to all group health insurance policies in which the health insurer has reserved the right to change the premium. L.1996,c.125,s.4.

N.J. Stat. § 17B:27-46.1oo Group health insurance policy to provide coverage regardless of gender identity, expression.

5. a. Notwithstanding any other law or regulation to the contrary, a group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State, by the Commissioner of Banking and Insurance on or after the effective date of this act, shall not contain any provision that discriminates, and the insurer shall not discriminate, on the basis of a covered person's or prospective covered person's gender identity or expression or on the basis that the covered person or prospective covered person is a transgender person. b. The discrimination prohibited by this section shall include: (1) denying, cancelling, limiting or refusing to issue or renew a policy on the basis of a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (2) demanding or requiring a payment or premium that is based in whole or in part on a covered person's or prospective covered person's gender identity or expression, or for the reason that the covered person or prospective covered person is a transgender person; (3) designating a covered person's or prospective covered person's gender identity or expression, or the fact that a covered person or prospective covered person is a transgender person, as a preexisting condition for which coverage will be denied or limited; or (4) denying or limiting coverage, or denying a claim, for services including but not limited to the following, due to a covered person's gender identity or expression or for the reason that the covered person is a transgender person: (a) health care services related to gender transition if coverage is available for those services under the policy when the services are not related to gender transition, including but not limited to hormone therapy, hysterectomy, mastectomy, and vocal training; or (b) health care services that are ordinarily or exclusively available to individuals of one sex when the denial or limitation is due only to the fact that the covered person is enrolled as belonging to the other sex or has undergone, or is in the process of undergoing, gender transition. c. For the purposes of this section: "Gender expression" means a person's gender-related appearance and behavior, whether or not stereotypically associated with the person's assigned sex at birth. "Gender identity" means a person's internal sense of their own gender, regardless of the sex the person was assigned at birth. "Gender transition" means the process of changing a person's outward appearance, including physical sex characteristics, to accord with the person's actual gender identity. "Transgender person" means a person who identifies as a gender different from the sex assigned to the person at birth. d. The provisions of this section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium. e. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service. L.2017, c.176, s.5.

N.J. Stat. § 17B:27-46.1p Coverage for minimum inpatient care following mastectomy by group policy

5. a. Every group policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide benefits 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 policy shall not require a health care provider to obtain authorization from the insurer 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 insurer under the policy. The benefits shall be provided to the same extent as for any other sickness under the policy. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. b. The Commissioner of Banking and Insurance shall adopt regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to implement the provisions of this section. L.1997,c.149,s.5.

N.J. Stat. § 17B:27-46.1pp Group health insurance policy to cover digital tomosynthesis of the breast.

5. a. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in conducting digital tomosynthesis to detect or screen for breast cancer in women 40 years of age and over; and for diagnostic purposes in women of any age. b. In the case of digital tomosynthesis conducted to detect or screen for breast cancer in women 40 years of age and over, no deductible, coinsurance or other cost sharing shall be applied; and in the case of digital tomosynthesis conducted for diagnostic purposes in women of any age, the same deductibles, coinsurance, and other cost sharing as apply to similar services under the policy shall be applied. c. This section shall apply to those group health insurance policies in which the insurer has reserved the right to change the premium. L.2017, c.305, s.5.

N.J. Stat. § 17B:27-46.1q Applicability of Health Care Quality Act

22. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy 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 policies in which the insurer has reserved the right to change the premium. L.1997,c.192,s.22.

N.J. Stat. § 17B:27-46.1qq Group health insurance policy to provide coverage for donated human breast milk.

N.J. Stat. § 17B:27-46.1r Coverage for treatment of inherited metabolic diseases by group health insurance policy.

5. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to each person covered thereunder for expenses incurred in the therapeutic treatment of inherited metabolic diseases, including the purchase of medical foods and low protein modified food products, when diagnosed and determined to be medically necessary by the covered person's physician. For the purposes of this section, "inherited metabolic disease" means a disease caused by an inherited abnormality of body chemistry for which testing is mandated pursuant to P.L.1977, c.321 (C.26:2-110 et seq.); "low protein modified food product" means a food product that is specially formulated to have less than one gram of protein per serving and is intended to be used under the direction of a physician for the dietary treatment of an inherited metabolic disease, but does not include a natural food that is naturally low in protein; and "medical food" means a food that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and is formulated to be consumed or administered enterally under direction of a physician. The benefits shall be provided to the same extent as for any other medical condition under the policy. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.1997,c.338,s.5.

N.J. Stat. § 17B:27-46.1rr Group health insurance policy to provide coverage for standard fertility preservation services.

4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for standard fertility preservation services when a medically necessary treatment may directly or indirectly cause iatrogenic infertility. For the purposes of this section: "Iatrogenic infertility" means an impairment of fertility caused by surgery, radiation, chemotherapy, or other medical treatment affecting reproductive organs or processes. "May directly or indirectly cause" means a medical treatment with a likely side effect of iatrogenic infertility as established by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" means procedures consistent with established medical practices and professional guidelines published by the American Society for Reproductive Medicine, the American Society of Clinical Oncology, or as defined by the New Jersey Department of Health. "Standard fertility preservation services" shall not include the storage of sperm or oocytes. The benefits shall be provided to the same extent as for any other medical condition under the policy. 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 policy. b. An insurer providing coverage under this section shall not determine the provision of standard fertility preservation services based on an insured'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 group health insurance policies in which the insurer has reserved the right to change the premium. L.2019, c.306, s.4.

N.J. Stat. § 17B:27-46.1s Group health insurer to cover certain audiology, speech-language pathology services.

5. Notwithstanding any other provision of chapter 27 of Title 17B of the New Jersey Statutes, benefits shall not be denied to any eligible individual for eligible services, as determined by the terms of the policy or as otherwise required by law, when the services are determined by a physician to be medically necessary and are performed or rendered to that individual by a licensed audiologist or speech-language pathologist within the scope of practice. The practices of audiology and speech-language pathology shall be deemed to be within the provisions of chapter 27 of Title 17B of the New Jersey Statutes and duly licensed audiologists and speech-language pathologists shall have such privileges and benefits in the scope of their practice under that act as are afforded thereunder to licensed physicians and surgeons in the scope of their practice. L.1997,c.419,s.5.

N.J. Stat. § 17B:27-46.1ss Group health insurer to provide coverage for breastfeeding support.

5. a. A group health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of P.L.2019, c.343 (C.17:48-6ss et al.), shall provide coverage for comprehensive lactation support, counseling, and consultation, and the costs for renting or purchasing breastfeeding equipment, in conjunction with each birth, for the duration of breastfeeding for health plan enrollees, with no cost-sharing. b. Coverage of breastfeeding equipment shall include: (1) Purchase of a single-user breast pump, subject to the following conditions: (a) A policy shall cover the purchase of a double electric breast pump. If an enrollee requests a manual pump in lieu of the double electric breast pump, the health plan shall cover the purchase of a manual pump. (b) A double electric breast pump provided pursuant to this paragraph shall be of sufficient power and durability to establish and maintain milk supply for the duration of breastfeeding. (c) A policy shall not require documentation of medical necessity, prior authorization, or a prescription for a breast pump provided pursuant to this paragraph. (d) Coverage shall be available at any time during pregnancy and the postpartum period, and shall continue for the duration of breastfeeding as defined by the plan enrollee. (e) Coverage for breast pumps shall include repair or replacement if necessary. (2) Rental or purchase of a multi-user breast pump, on the recommendation of a licensed health care provider, subject to the following conditions: (a) When recommended by a licensed health care provider, a policy shall provide coverage for a multi-user breast pump. (b) A group health insurer may determine whether a rental or purchase is covered. (c) Coverage for a multi-user breast pump shall be covered without regard to coverage or acquisition of a single-user breast pump. (d) A group health insurer may require a letter of medical necessity from a lactation consultant or other health care provider for coverage of a multi-user pump. The letter shall not interfere with the timely acquisition of a multi-user pump. (3) Coverage of breastfeeding equipment pursuant to this section shall include two breast pump kits per birth event, as well as appropriate size breast pump flanges, or other lactation accessories recommended by a health care provider. (4) Breastfeeding equipment specified in paragraphs (1) and (3) of this subsection shall be furnished: within 48 hours of notification of need, if requested after the birth of the child; or by the later of two weeks before the enrollee's expected due date or 72 hours after notification, if requested prior to the birth of the child. If the group health insurer cannot ensure an enrollee receives breastfeeding equipment within 48 hours, an enrollee may purchase the equipment and the health plan shall reimburse all out-of-pocket expenses incurred by the enrollee, including any balance billing amounts. (5) Breastfeeding equipment specified in paragraph (2) of this subsection shall be made available within 12 hours of notification of need. If equipment is not available within 12 hours of notification of need, the group health insurer shall reimburse all out-of-pocket rental expenses incurred by an enrollee, including any balance billing amounts, until the enrollee receives breastfeeding equipment. c. Coverage of comprehensive lactation counseling and lactation consultation shall include: (1) In-person, one-on-one lactation counseling and lactation consultation, subject to the following conditions: (a) Coverage shall include visits that occur inside and outside a hospital or office setting. In-person lactation counseling and lactation consultation shall be covered regardless of location of service provision and shall include home visits. (b) Lactation counseling and lactation consultation shall be made available within 24 hours of notification of need. (2) Telephonic lactation assistance shall be covered in addition to, and not as a substitute for, in-person, one-on-one lactation counseling or lactation consultation, when an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. The telephonic lactation assistance shall be provided within 12 hours of notification of need. (3) Group lactation counseling shall be covered in addition to, and not as a substitute for, one-on-one, in-person lactation counseling or lactation consultation, if an enrollee requests one-on-one, in-person lactation counseling or lactation consultation. Group counseling shall include educational classes and support groups. (4) A policy shall not require prior authorization, prescription or referral for any lactation counseling or lactation consultation, regardless of provider type or setting. (5) A group health insurer shall not impose medical management techniques not described in this section. d. Except as otherwise authorized pursuant to this section, a group health insurer shall not impose restrictions on the coverage provided pursuant to this section, including, but not limited to, limitations on reimbursement to allowable amounts or reasonable and customary charges, documentation requests, or delays on the coverage provided. e. As used in this section: "Cost-sharing" means deductible, co-insurance or co-payments, or similar charges. "Breast pump kit" means a collection of tubing, valves, flanges, collection bottles, or other parts required to extract human milk using a breast pump. "Lactation consultant" means an individual who is an International Board Certified Lactation Consultant. "Lactation consultation" means the clinical application by a lactation consultant or other licensed health care provider of scientific principles and a multidisciplinary body of evidence for evaluation, problem identification, treatment, education, and consultation to child-bearing families utilizing lactation care and services. Lactation care and services shall include, but not be limited to: (1) lactation assessment through the systematic collection of subjective and objective data; (2) analysis of data and creation of a plan of care; (3) implementation of a lactation care plan with demonstration and instruction to parents and communication to the primary health care provider; (4) evaluation of outcomes; (5) provision of lactation education to parents and health care providers; and (6) the recommendation and use of assistive devices. "Lactation counseling" means breastfeeding education and support services provided by a lactation counselor, such as: (1) educating women, families, health care professionals, and the community about the impact of breastfeeding and human lactation on health and what to expect in the normal course of breastfeeding; (2) acting as an advocate for breastfeeding as the norm for feeding infants and young children; (3) providing breastfeeding support, encouragement, and care from preconception to weaning in order to help women and their families meet their breastfeeding goals; (4) using principles of adult education when teaching clients, health care providers, and others in the community; and (5) identifying and referring high-risk mothers and babies and those requiring clinical treatment appropriately. "Lactation counselor" means an individual, other than an International Board Certified Lactation Consultant or a licensed health care provider, who is: (1) licensed or certified to practice lactation counseling under any law, or who is an accredited member belonging to another profession or occupation, who provides breastfeeding education and support services for which that person is licensed, regulated, accredited, or certified; or (2) a community-based lactation supporter who has received at least 40 hours of specialty education in breastfeeding and lactation, and who works within a lactation counselor's scope of practice. "Telephonic lactation assistance" means lactation counseling or consultation with a lactation counselor or lactation consultant conducted remotely through live voice communication. f. This section shall apply to those policies in which the group health insurer has reserved the right to change the premium. L.2019, c.343, s.5.

N.J. Stat. § 17B:27-46.1t Coverage for treatment of domestic violence injuries by group health insurance policy.

5. Except as otherwise provided in P.L.1992, c.162 (C.17B:27A-17 et seq.), no group health insurance policy providing hospital or medical expense benefits shall contain any provision which denies benefits for expenses incurred in the treatment of an injury or injuries sustained as the result of domestic violence as defined in section 3 of P.L.1991, c.261 (C.2C:25-19), to a named insured or other person covered thereunder. Benefits shall be provided to the same extent as for any other treatment under the policy. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.1998,c.97,s.5.

N.J. Stat. § 17B:27-46.1tt Group health insurer policy to cover preventive services.

5. a. A group health insurer policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage, without requiring any cost sharing, for the following preventive services: (1) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force; (2) immunizations that have in effect a recommendation from the 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 policy which has a network of providers to provide benefits for items or services described in subsection a. of this section that are delivered by an out-of-network provider; or (b) preclude a policy which has a network of providers from imposing cost-sharing requirements for items or services described in subsection a. of this section that are delivered by an out-of-network provider. (2) If a policy does not have in its network a provider who can provide an item or service described in subsection a. of this section, the policy shall cover the item or service when performed by an out-of-network provider and shall not impose cost sharing with respect to that item or service. c. (1) A policy shall provide coverage for an item or service described in subsection a. of this section for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued. (2) (a) Except as provided in subparagraph (b) of this paragraph, a policy that is required to provide coverage for an item or service described in subsection a. of this section on the first day of a plan year shall provide coverage for that item or service through the last day of the plan year. (b) The commissioner may remove a coverage requirement for an item or service during a plan year if the recommendation or guideline changes or is no longer described in subsection a. of this section. d. This section shall apply to those policies in which the insurer has reserved the right to change the premium. 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 policy, but may not impose a waiting period for the wellness visit. L.2019, c.360, s.5; amended 2025, c.283, s.7; 2025, c.386, s.5.

N.J. Stat. § 17B:27-46.1u Coverage for certain dental procedures for the severely disabled or child age five or under by group health insurance policy

5. a. No group health insurance policy providing hospital or medical benefits shall be delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this amendatory and supplementary act, unless the policy provides benefits to any person covered thereunder who is severely disabled or a child age five or under for expenses incurred for: (1) general anesthesia and hospitalization for dental services; or (2) a medical condition covered by the contract which requires hospitalization or general anesthesia for dental services rendered by a dentist regardless of where the dental services are provided. b. A group health insurance policy may require prior authorization of hospitalization for dental services in the same manner that prior authorization is required for hospitalization for other covered diseases or conditions. c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium. L.1999,c.49,s.5.

N.J. Stat. § 17B:27-46.1uu Group health insurance policy to provide certain coverage for prescription drugs.

5. a. Notwithstanding any other provision of law to the contrary, an insurer that offers a group health insurance policy that provides benefits for expenses incurred in the purchase of prescription drugs and is delivered, issued, executed, or renewed in this State, shall ensure that the insurer offers at least two plans in the large group market pursuant to N.J.S.17B:27-26 et seq. b. The provisions of the section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2019, c.471, s.5.

N.J. Stat. § 17B:27-46.1v Group health insurers to provide coverage for mental health conditions, substance use disorders; collaborative care model.

5. a. (1) Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide benefits for mental health conditions and substance use disorders under the same terms and conditions as provided for any other sickness under the policy 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 insurer cannot apply more restrictive non-quantitative limitations, such as utilization review and other criteria or more quantitative limitations such as copayments, deductibles, aggregate or annual limits or benefit limits to mental health condition and substance use disorder benefits than those applied to substantially all other medical or surgical benefits. "Substance use disorder" means a disorder defined to be consistent with generally recognized independent standards of current medical practice referenced in the most current version of the Diagnostic and Statistical Manual of Mental Disorders. b. (Deleted by amendment, P.L.2019, c.59) c. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. d. Nothing in this section shall reduce the requirement for an insurer to provide benefits pursuant to section 5 of P.L.2017, c.28 (C.17B:27-46.1nn). L.1999, c.106, s.5; amended 2019, c.58, s.5; 2022, c.33, s.5.

N.J. Stat. § 17B:27-46.1vv Group health insurance policy to cover adolescent depression screenings.

5. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred in screening adolescents between the ages of 12 and 18 for major depressive disorder, so long as screening for major depressive disorder in adolescents continues to receive a rating of "A" or "B" from the United States Preventative Services Task Force. Coverage shall not be denied solely on the basis that the screening is provided in conjunction with any other health care evaluation, treatment, or service. The benefits shall be provided to the same extent as for any other condition under the policy, except that the insurer shall not impose on covered persons receiving these services any form of cost sharing, including, but not limited to, copayments, deductibles, or coinsurance. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2021, c.73, s.5.

N.J. Stat. § 17B:27-46.1w Coverage for hemophilia services by group health insurers

4. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of P.L.2000, c.121 (C.26:2S-10.1 et al.) unless the policy meets the requirements of sections 1 and 2 of P.L.2000, c.121 (C.26:2S-10.1 and C.26:2S-10.2) and the regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2000,c.121,s.4.

N.J. Stat. § 17B:27-46.1ww Group health insurance policy, coverage, epinephrine auto-injector device.

14. A group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide coverage for at least one epinephrine auto-injector device, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of an epinephrine auto-injector device shall not be subject to any deductible, and no copayment or coinsurance for the purchase of an epinephrine auto-injector device shall exceed $25 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent a group health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.14.

N.J. Stat. § 17B:27-46.1x Group health insurance policy to provide coverage for treatment of infertility.

4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the policy provides coverage for persons covered under the policy for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The policy shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The policy 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 policy 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 policy, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed. b. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3). c. This section shall apply to those insurance policies in which the insurer has reserved the right to change the premium. d. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the 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 insurer 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.4; amended 2017, c.48, s.4; 2023, c.258, s.4.

N.J. Stat. § 17B:27-46.1xx Group health insurance policy, coverage, prescription asthma inhaler.

15. A group health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed, or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of P.L.2023, c.105 (C.17:48-6xx et al.) shall provide benefits to a person covered thereunder for expenses incurred for a prescription asthma inhaler, if recommended or prescribed by a participating physician or participating nurse practitioner/clinical nurse specialist. Coverage for the purchase of a covered prescription asthma inhaler shall not be subject to any deductible, and no copayment or coinsurance for the purchase of a covered prescription asthma inhaler shall exceed $50 per 30-day supply. The provisions of this section shall apply to a high-deductible health plan to the maximum extent permitted by federal law, except if the plan is used to establish a medical savings account pursuant to section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220) or a health savings account pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223). The provisions of this section shall apply to the plan to the maximum extent that is permitted by federal law and does not disqualify the account for the deduction allowed under section 220 or 223, as applicable. The provisions of this section shall apply to a plan that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, to the maximum extent permitted by federal law. Nothing in this section shall prevent a group health insurer from reducing a covered person's cost-sharing requirement by an amount greater than the amount specified in this section. L.2023, c.105, s.15.

N.J. Stat. § 17B:27-46.1y Group policy to provide coverage for colorectal cancer screening.

5. a. Every group policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any named insured or other person covered thereunder for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recently published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person. b. No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force. c. The benefits shall be provided to the same extent as for any other medical condition under the policy. d. The provisions of this section shall apply to all health insurance policies in which the insurer has reserved the right to change the premium. L.2001,c.295,s.5; amended 2023, c.8, s.5.

N.J. Stat. § 17B:27-46.1yy Biomarker precision medical testing coverage, group health insurance policies.

5. a. Each group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed, or renewed in this State pursuant to chapter 27 of Title 17B of the New Jersey Statutes or is approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide benefits for biomarker precision medical testing, as defined by subsection g. of this section. b. Biomarker precision medical testing shall be covered for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a disease or condition, excluding asymptomatic screening, to guide treatment decisions of an insured when the efficacy and appropriateness of biomarker precision medical testing for the diagnosis, treatment, appropriate management, or guiding treatment decisions for an insured's disease or condition is recognized by: (1) labeled indications for an FDA-approved or -cleared test; (2) indicated tests for an FDA-approved drug; (3) actions to address warnings and precautions on FDA-approved drug labels; (4) Centers for Medicare and Medicaid Services National Coverage Determinations or Medicare Administrative Contractor Local Coverage Determinations; or (5) nationally recognized clinical practice guidelines. c. Coverage, pursuant to subsection b. of this section, shall be provided in a manner that limits disruption, including multiple biopsies or biospecimen samples, in the care of an insured. d. (1) If utilization review is required, an insurer shall provide a decision pursuant to the guidelines and timeframes set forth in P.L.2023, c.296 (C.17B:30-55.1 et al.). (2) The insured and the treating health care provider or treating health care entity prescribing biomarker precision medical testing for the insured shall have access to clear, readily accessible, and conspicuous information on the process to submit an appeal to an adverse determination. e. The benefits shall be provided to the same extent as for any other medical condition under the contract, including determinations of clinical review criteria used for utilization review of health care services along with copayment, deductible, and coinsurance provisions. f. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. g. As used in this section: "Biomarker" means a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a specific therapeutic intervention, including known gene-drug interactions for medications being considered for use or already being administered. Biomarkers shall also include, but not be limited to, gene mutations, characteristics of genes, or protein expression. "Biomarker precision medical testing" means the analysis of tissue, blood, or other biospecimen for the presence of a biomarker. Biomarker precision medical testing includes, but is not limited to, single-analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing. "Nationally recognized clinical practice guidelines" means evidence-based clinical practice guidelines developed by independent organizations or medical professional societies utilizing a transparent methodology and reporting structure and with a conflict of interest policy. The guidelines establish standards of care informed by a systematic review of evidence and an assessment of the benefits and risks of alternative care options and include recommendations intended to optimize patient care. L.2025, c.49, s.5.

N.J. Stat. § 17B:27-46.1z Group health insurer prescription drug plans to cover certain infant formulas.

4. A group health insurer which provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a policy that is delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits under the policy for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant's physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk. The coverage may be subject to utilization review, including periodic review, of the continued medical necessity of the specialized infant formula. The benefits shall be provided to the same extent as for any other prescribed items under the policy. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2001,c.361,s.4.

N.J. Stat. § 17B:27-46.1zz Group health insurance policy, HIV preexposure prophylaxis, HIV postexposure prophylaxis.

7. a. (1) Except as provided in paragraph (2) of this subsection, no group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for HIV preexposure prophylaxis and HIV postexposure prophylaxis furnished without an individual prescription pursuant to the requirements of section 2 of P.L.2025, c.196 (C.45:14-67.13) without requiring prior authorization or step therapy. (2) If the federal Food and Drug Administration has authorized or approved one or more therapeutic equivalents of a drug, device, or product for the prevention of HIV and AIDS, paragraph (1) of this subsection shall not be construed to require the policy to cover all therapeutically equivalent versions without prior authorization or step therapy, if at least one version is covered without prior authorization or step therapy. b. Reimbursement issued under this section to a pharmacist shall be at a rate that is no less than the rate provided by the group health insurance policy to other non-physician practitioners if the reimbursement is for a service or procedure that meets the following criteria: (1) the service or procedure is within the scope of practice of the treating pharmacist; and (2) the service or procedure would otherwise be covered under the policy if provided by a healthcare provider, including a physician, advanced practice nurse, or physician assistant. c. A group health insurance policy shall grant a licensed pharmacist receiving reimbursement under this section the same rights of participation, plan admission, and registration as may be granted by the policy to a healthcare provider, including a physician, advanced practice nurse, or physician assistant, who is reimbursed for an identical service. d.A group health insurance policy shall not: (1) prohibit, or permit a delegated pharmacy benefits manager to prohibit, a pharmacist from dispensing HIV preexposure prophylaxis or HIV postexposure prophylaxis; and (2) be required to cover HIV preexposure prophylaxis that has been furnished by a pharmacist without an individual prescription pursuant to pursuant to section 2 of P.L.2025, c.196 (C.45:14-67.13) in excess of a 90-day supply for a single patient within a given two year period. e. Nothing in this section shall be construed to require a group health insurance policy to provide coverage for HIV preexposure prophylaxis or HIV postexposure prophylaxis furnished by a pharmacist at an out-of-network pharmacy, unless the contract has an out-of-network pharmacy benefit. f. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. g. As used in this section: “HIV preexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). “HIV postexposure prophylaxis” means the same as that term is defined in section 1 of P.L.2025, c.196 (C.45:14-67.12). “Step therapy” means requiring that a lower-cost alternative to HIV preexposure prophylaxis or HIV postexposure prophylaxis be shown to have been ineffective as a condition of providing prescription benefits. L.2025, c.196, s.7.

N.J. Stat. § 17B:27-46.2 Second surgical opinions; definitions

As used in this act: a. "Elective surgical procedure" means any nonemergency surgical procedure which may be scheduled at the convenience of the patient or the surgeon without jeopardizing the patient's life or causing serious impairment to the patient's bodily functions. b. "Second surgical opinion" means an opinion of an eligible physician based on that physician's examination of a person for the purpose of evaluating the medical advisability of that person undergoing an elective surgical procedure. The examination must be performed after another physician licensed to practice medicine and surgery has proposed to perform such surgical procedure on the person but prior to the performance of such surgical procedure. c. "Eligible physician" means a physician licensed to practice medicine and surgery who holds the rank of Diplomate of an American Board (M.D.) or Certified Specialist (D.O.) in the surgical or medical specialty for which surgery is proposed. L.1979, c. 329, s. 1.

N.J. Stat. § 17B:27-46.3 Group insurance policies; provision of program on request

Any insurer issuing a group insurance policy in accordance with chapter 27 of Title 17B of the New Jersey Statutes which provides coverage of surgical operations performed on a person while confined in a hospital as an inpatient shall make available, and if requested by the group policyholder, provide a second surgical opinion program for elective surgical procedures which would require inpatient admission to a hospital for persons insured under the group policy for such surgical coverage. L.1979, c. 329, s. 2.

N.J. Stat. § 17B:27-46.4 Payment for second surgical opinion services

A second surgical opinion program shall provide for payment for the second surgical opinion services of an eligible physician and for essential laboratory and X-ray services incidental thereto, either as a benefit under the group policy or, at the insurer's option, by a separate arrangement with the group policyholder. The program may be limited to eligible physicians who have agreed to participate in the insurer's second surgical opinion program. If the benefits are provided by the group insurance policy, the amount shall be reasonably related to amounts payable under the group policy for covered surgical procedures. L.1979, c. 329, s. 3.

N.J. Stat. § 17B:27-46.5 Third surgical opinion

If a second surgical opinion does not confirm that a proposed elective surgical procedure is medically advisable, the program must cover a third surgical opinion in the same manner as the second opinion. L.1979, c. 329, s. 4.

N.J. Stat. § 17B:27-46.6 Reduction of benefits where no second opinion obtained

Where a second surgical opinion program is operative in connection with surgical coverage under a group insurance policy, and provides second and third surgical opinion services at no cost to the insured or patient, the group policy may, as an incentive to encourage utilization of the program when elective surgery is proposed, provide reduced benefits for the surgeon's charges for such elective surgery if it is performed without first obtaining a second or third opinion confirming that the proposed elective surgery was advisable. L.1979, c. 329, s. 5.

N.J. Stat. § 17B:27-46.7 Permissible benefit exclusions

A second surgical opinion program may exclude benefits while the patient is confined in a hospital as an inpatient, any surgical procedure not covered by the group insurance policy, and surgical procedures in the following categories: cosmetic surgery, dental surgery, and podiatric surgery. L. 1979, c. 329, s. 6. Amended by L. 1985, c. 277, s. 1.

N.J. Stat. § 17B:27-46.8 Payment for opinion services of physician

If a physician who furnishes a second or third surgical opinion also performs the surgical procedure, the second surgical opinion program need not provide payment for the second or third opinion services of that physician. L.1979, c. 329, s. 7.

N.J. Stat. § 17B:27-46.9 Application of act

This act shall apply to all contracts in which the insurer has reserved the right to change the premium. L.1979, c. 329, s. 8.

N.J. Stat. § 17B:27-46.10 Group health insurance policy to cover newborn home care visitation.

9. a. No group health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed, or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159). The policy shall: (1) provide coverage for the services provided by the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159); (2) notify a covered person of the services provided by the newborn home nurse visitation program, upon application by the covered person for coverage of a newborn infant; (3) ensure that the policy does not contain any provision that requires a covered person to receive the services provided by the newborn home nurse visitation program as a condition of coverage, or that denies or limits benefits to the covered person if that person declines the services provided under the program; and (4) have the discretion to determine how best to reimburse for the expenses incurred for services provided under the newborn home nurse visitation program, including, but not limited to, utilizing: (a) a value-based payment methodology; (b) an invoice claim process; (c) a capitated payment arrangement; (d) a payment methodology that takes into account the need for an agency or organization providing services under the program to expand its capacity to provide services and address health disparities; or (e) any other payment arrangement agreed to by the insurer and an agency or organization providing services under the program. b. Any copayment, coinsurance, or deductible that may be required pursuant to the policy for such services shall be waived. c. Every insurer 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 group health insurance policy that qualifies as a high deductible health plan shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement permitted for a high deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223). (3) A group health insurance policy that meets the requirements of a catastrophic plan, as defined in 45 C.F.R. s.156.155, shall provide benefits for expenses incurred for services provided under the newborn home nurse visitation program established pursuant to section 2 of P.L.2021, c.187 (C.26:2H-159) at the lowest deductible and other cost-sharing requirement to the extent permitted for a catastrophic plan under federal law. e. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium. L.2021, c.187, s.9.

N.J. Stat. § 17B:27-47 Group health or blanket insurance--provisions as favorable; policies issued outside State

No policy of group health or blanket insurance, and no certificate thereunder shall be delivered or issued for delivery in this State if such policy or certificate contains any provision inconsistent with any of the provisions of this chapter, except that such policy may contain any provision which in the opinion of the commissioner is as favorable to policyholders or certificate holders as the provision herein required, and except that such policy issued by any insurer of this State for delivery outside of this State may contain any provision not consistent with the provisions of this chapter; provided, such policy conforms to the laws of the State or country in which it is delivered. L.1971, c. 144, s. 17B:27-47.

N.J. Stat. § 17B:27-48 Exceptions in same type as benefits

Exceptions in the policy shall be printed in the policy and in the certificate with the same prominence as the benefits to which they apply. L.1971, c. 144, s. 17B:27-48.

N.J. Stat. § 17B:27-49 Filing of forms

17B:27-49. a. No group health insurance policy, or blanket insurance policy, or application, if a written application is required and is to be made a part of the policy, certificate, printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the commissioner in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2). b. (Deleted by amendment, P.L.1995, c.73.) c. If a form is disapproved for filing by the commissioner during the 60-day period, it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d. of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval 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. (Deleted by amendment, P.L.1995, c.73.) e. (Deleted by amendment, P.L.1995, c.73.) f. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under such policies and which are used at the request of the individual insured or policyholder. g. The disapproval by the commissioner of any such form may be on the ground that such form contains provisions which are unjust, unfair, inequitable, misleading, contrary to law or to the public policy of this State. L.1971, c.144; amended 1995,c.73,s.21.

N.J. Stat. § 17B:27-50 Reimbursement for service of physician or practicing psychologist

a. Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed practicing psychologist, a person covered under such group health policy or contract shall be entitled to reimbursement for such service whether the said service is performed by a physician or duly licensed practicing psychologist. b. The foregoing provision shall be liberally construed in favor of reimbursement and no claim for reimbursement shall be denied by reason of: (1) The fact that physical delivery of a policy or contract of group health insurance or any package of insurance of which group health insurance is a part, or of a contract, certificate or other evidence of insurance coverage drawn thereunder, was made outside this State, provided, the member of the group covered is, at the time of delivery or at any time thereafter to the time of reimbursement, either (a) a resident of this State, or (b) a nonresident employed in this State and the said policy or contract is related to or arose out of such employment; or (2) The inclusion in such policy or contract of a description or designation of the person rendering the services for which reimbursement is sought as a "physician" or "psychiatrist," or other professional designation; or (3) The fact that the psychiatric or psychologist services rendered by a licensed psychologist for which reimbursement is sought are such as might also be lawfully rendered by a physician or psychiatrist as medical care, services or treatment under the laws of this State. c. Any person insured under any policy or contract of group health insurance or blanket insurance, whether written separately or as part of a package policy, which policy or contract is issued, delivered, amended, renewed, or ratified on or after 3 months from the effective date of this act, and, in any event, any person insured under any policy or contract of group health insurance or blanket insurance, written separately or as part of a package policy, which is in effect on or after July 1, 1974, shall be entitled to reimbursement for any service rendered by a practicing psychologist, provided, reimbursement is authorized in such policy or contract for services of the same or similar nature and scope, and further provided, the services for which reimbursement is claimed are within the lawful scope of practice of a practicing psychologist, whether the service is performed by a physician or a psychiatrist or duly licensed practicing psychologist at any time while the policy is in effect; and further provided (1) such person is a resident of this State, or, (2) the policy or contract is related to or arises out of employment and the member of the group seeking reimbursement is engaged in such employment in this State, or (3) the policy or contract, or certificate of insurance thereunder, or amendment, renewal, or notification thereof, is either issued or delivered in this State. L.1971, c. 144, s. 17B:27-50. Amended by 1973, c. 340, s. 1, eff. Dec. 27, 1973.

N.J. Stat. § 17B:27-50.1 Severability

If any section, subsection, paragraph, sentence, clause, phrase or word contained in this act shall be declared invalid for any reason whatsoever, such invalidity shall not effect the remaining portions of this act which shall remain in full force and effect, and, to this end, the provisions of this act are hereby declared to be severable. L.1973, c. 340, s. 2, eff. Dec. 27, 1973.

N.J. Stat. § 17B:27-51 Reimbursement for optometric service

Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any optometric service which is within the lawful scope of practice of a duly licensed optometrist, a person covered under such group health policy or contract shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed optometrist. L.1971, c. 144, s. 17B:27-51.

N.J. Stat. § 17B:27-51.1 Reimbursement for service of chiropractor

Notwithstanding any provision of a policy or contract of group health insurance, hereafter delivered or issued for delivery in this State, whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed chiropractor, a person covered under such group health policy or contract or the chiropractor rendering such service shall be entitled to reimbursement for such service when the said service is performed by a chiropractor. The foregoing provision shall be liberally construed in favor of reimbursement of chiropractors. L.1975, c. 125, s. 1, eff. June 5, 1975.

N.J. Stat. § 17B:27-51.1a Group health insurance benefits for certain nursing services

2. a. Notwithstanding any provision of a policy of group health insurance, whenever such a policy provides for reimbursement for any service which is within the lawful scope of practice of a duly registered professional nurse who is not being paid a salary by a health care provider for the services so performed, a person covered under that group health insurance policy or the registered professional nurse rendering the service shall be entitled to reimbursement for the service. b. This act shall exclude salaried services which are already reimbursed and shall not be construed to affect or impair hospital procedures for billing in-hospital nursing care. The practice of nursing shall be deemed to be within the provisions of chapter 27 of Title 17B of the New Jersey Statutes and duly registered professional nurses shall have those privileges and benefits in the scope of their practice as are afforded thereunder to licensed physicians and surgeons in the scope of their practice. c. This section shall apply to any group health insurance policy: (1) delivered or issued for delivery in this State on or after the effective date of this act; or (2) under which the insurer reserves the right to change the premium. L.1992,c.128,s.2.

N.J. Stat. § 17B:27-51.2 Legislative findings and declarations

The Legislature hereby finds and declares that the high cost of hospital care necessitates the establishment of alternative means of caring for patients who need some professional health care, but who do not need to remain hospitalized. Home health care, therefore, is a necessary and desirable means of providing professional services to patients, consistent with the following objectives: a. Rehabilitation of the patient in order to assist in the development of independent living capabilities; b. Rehabilitation of the patient in order to attain reduction of physical or mental disability. L.1977, c. 99, s. 1.

N.J. Stat. § 17B:27-51.3 Definitions

As used in this act: a. "Home health care" means those nursing and other home health care services rendered to a person in his place of residence, under the following conditions: (1) On a part-time and intermittent basis, except when full-time or 24-hour services are needed on a short-term basis; (2) If continuing hospitalization would otherwise have been required if home health care were not provided; (3) Pursuant to a physician's order and under a plan of care established by the responsible physician in collaboration with a home health care provider, which plan shall be periodically reviewed and approved by said physician. All care plans shall be established within 14 days following the commencement of home health care. b. "Home health care services" means any of the following services necessary for achievement of the care plan set forth for the patient: (1) Nursing care; (2) Physical therapy; (3) Occupational therapy; (4) Medical social work; (5) Nutrition services; (6) Speech therapy; (7) Home health aide services; (8) Medical appliances and equipment, drugs and medications, laboratory services and special meals, to the extent such items and services would have been covered under the policy if the covered person had been in a hospital; (9) Any diagnostic or therapeutic service, including surgical services, performed in a hospital outpatient department, a doctor's office or any other licensed health care facility, provided such service would have been covered under the policy if performed as inpatient hospital services. c. "Home health care provider" means a home health care agency which is certified to participate as a home health agency under Title XVIII of the Social Security Act or a proprietary agency licensed by the Commissioner of Health. At such time as home health agency licensure standards are promulgated pursuant to c. 136 and 138, P.L.1971, home health care providers shall be licensed agencies. L.1977, c. 99, s. 2.

N.J. Stat. § 17B:27-51.4 Home health care; requirement for coverage

Notwithstanding any provision of a policy of group health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides coverage for inpatient hospital care or skilled nursing facility care, it shall also provide coverage for home health care. L.1977, c. 99, s. 3.

N.J. Stat. § 17B:27-51.5 Benefits

Every policy shall provide benefits required by section 3 without a separate deductible or coinsurance provision for the home health care benefit. For the purpose of determining the benefits for home health care, each visit by a member of a home health care team shall be considered as one home health care visit. The policy may contain a limitation on the number of home health care visits, but no policy may provide for less than 60 home health care visits in any calendar year or in any continuous period of 12 months. L.1977, c. 99, s. 4.

N.J. Stat. § 17B:27-51.6 Direct reimbursement to home health care providers

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, shall provide for a system of direct reimbursement to home health care providers for services rendered pursuant to this act. L.1977, c. 99, s. 5.

N.J. Stat. § 17B:27-51.7 Regulations

The State Commissioner of Insurance, after consultation with the State Commissioner of Health, is hereby empowered and directed to promulgate regulations necessary to effectuate the provisions of this act. L.1977, c. 99, s. 6.

N.J. Stat. § 17B:27-51.8 Policy provision for reimbursement of dental services; payment regardless of discipline of provider

Notwithstanding any provision of a policy or contract of group health insurance hereafter delivered, issued for delivery, amended, renewed or ratified in this State whenever such a policy or contract provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed dentist, the following provisions shall apply: a. A person covered under such group health policy or contract shall be entitled to reimbursement for such service regardless of whether the service is performed by a duly licensed physician or duly licensed dentist. b. Equal reimbursement rates shall be paid for services performed, regardless of the discipline of the provider of the service. L.1979, c. 158, s. 1, eff. July 19, 1979.

N.J. Stat. § 17B:27-51.9 Application to policy or contract not limited to reimbursement of specific types of duly licensed health care professionals other than dentists

The provisions of section 1 of this act shall also apply to any policy or contract of group health insurance already delivered or issued for delivery in this State, if such policy or contract does not limit reimbursement to specific types of duly licensed health care professionals other than dentists. L.1979, c. 158, s. 2, eff. July 19, 1979.

N.J. Stat. § 17B:27-51.10 Renewal date; policy with reservation of right to change premium

For the purposes of this act, a policy or contract in which the company has reserved the right to change the premium shall be considered renewed as of the date on which the premium is changed or is subject to change. L.1979, c. 158, s. 3, eff. July 19, 1979.

N.J. Stat. § 17B:27-51.10a Alternative dental coverage; original coverage restricted to limited number of providers

Each employer or other organization which employs or has 25 or more employees or members during the full preceding calendar year which contributes to a group health insurance contract which restricts the covered persons in selecting the providers of dental services to a single provider or limited number of providers, shall also offer its employees or their eligible dependents or members or members' eligible dependents at the time a dental benefits plan is offered or renewed the option of selecting alternative coverage which permits covered persons to obtain dental services from any licensed dentist. L.1983, c. 145, s. 1, eff. April 20, 1983.

N.J. Stat. § 17B:27-51.10b Employer contribution

An employer or other organization shall be required to pay or contribute towards the provision of alternative coverage an amount equal to the premium or cost which it pays or contributes to the group health insurance contract for dental services which limits the number of providers of dental services. L.1983, c. 145, s. 2, eff. April 20, 1983.

N.J. Stat. § 17B:27-51.10c Rules and regulations

Within 120 days of the effective date of this act, the Commissioner of the Department of Insurance shall promulgate rules and regulations necessary to effectuate the purpose of this act, including procedures for notice to covered persons, employers and other organizations of the provisions of this act. L.1983, c. 145, s. 3, eff. April 20, 1983.

N.J. Stat. § 17B:27-51.11 Definitions

As used in this act: a. "Group policy" means a group health insurance policy issued by an insurer pursuant to Title 17B of the New Jersey Statutes. b. "Insurer" means the entity issuing a group policy or an individual policy or converted policy. c. "Insurance" , "Insures" and "Insured" refer to coverage under a group policy on a premium-paying basis. d. "Premium" includes any premium or other consideration payable for coverage under a group or individual policy. e. "Medicare" means Title XVIII of the United States Social Security Act as amended or superseded. f. "Total disability of the employee or member" exists only while the employee or member (1) is not engaged in any gainful occupation, and (2) is completely unable, due to sickness or injury or both, to engage in any and every gainful occupation for which the person is reasonably fitted by education, training or experience. L.1981, c. 422, s. 1.

N.J. Stat. § 17B:27-51.12 Total disability of employee or member; continuation under group policy; conditions

A group policy delivered or issued for delivery in this State which insures employees or members and their dependents for hospital, surgical or major medical insurance on an expense incurred or service basis, other than for specific diseases or for accidental injuries only, shall provide that employees or members whose insurance under the group policy would otherwise terminate because of termination of employment or membership due to total disability of the employee or member shall be entitled to continue their hospital, surgical and major medical insurance under that group policy, for themselves and their eligible dependents, subject to all of the group policy's terms and conditions applicable to those forms of insurance and subject to the following conditions: a. Continuation shall only be available to any employee or member who has been continuously insured under the group policy during the entire 3-month period ending with such termination. b. Continuation shall be available for any person who is covered by or eligible for Medicare, subject to any nonduplication of benefits provisions in the group policy. c. In addition to hospital, surgical, or major medical benefits, continuation shall include all other health care expense benefits provided under the group policy, including dental, vision care, or prescription drug benefits. d. An employee or member electing continuation shall pay to the group policyholder or his employer, on a monthly basis in advance, the amount of contribution required by the policyholder or employer, but not more than the group rate for the insurance being continued under the group policy on the due date of each payment. The employee's or member's written election for continuation, together with the first contribution required to establish contributions on a monthly basis in advance, shall be given to the policyholder or employer within 31 days of the date the employee's or member's insurance would otherwise terminate. e. Continuation of insurance under the group policy for any person shall terminate at the first to occur of the following: (1) Failure of the former employee or member to make timely payment of a required contribution. Termination shall occur at the end of the period for which contributions were made. (2) The date the employee again becomes employed and eligible for benefits under another group plan providing health care expense benefits, or in the case of a qualified dependent, the date such qualified dependent becomes employed and eligible for such benefits. (3) The date on which the group policy is terminated or, in the case of an employee, the date his employer terminates participation under the group policy, provided that (a) The employee or member shall have the right to become covered under any new group policy contracted for by the employer, for the balance of the period that he would have remained covered under the prior group policy in accordance with this act had a termination of a group not occurred; (b) The minimum level of benefits to be provided by the other group policy shall be the applicable level of benefits of the prior group policy reduced by any benefits payable under that prior group policy; and (c) The prior group policy shall continue to provide benefits to the extent of its accrued liabilities and extensions of benefits as if the replacement had not occurred. f. A notification of the continuation privilege shall be included in each certificate of coverage. L.1981, c. 422, s. 2.

N.J. Stat. § 17B:27-51.13 Inapplicability to policy without right of insurer to terminate without consent of insured

The provisions of this act shall not apply to any policy in which the insurer does not have the right to terminate the policy without the consent of the insured. L.1981, c. 422, s. 3.

N.J. Stat. § 17B:27-51.14 Insurer provide health benefits plan, aggregate benefits.

4. a. Beginning with the calendar year starting on January 1, 2020, and in each calendar year thereafter, an insurer providing a health benefits plan shall return, in the form of aggregate benefits for all large group health insurance policy forms offered by the insurer pursuant to N.J.S.17B:27-26 et seq., at least 85 percent of the aggregate premiums collected for all of the policy forms. b. An insurer shall annually report to the Commissioner of Banking and Insurance, no later than August 1 of each year, the loss ratio calculated for all of the policy forms 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 insurer shall issue a dividend or credit against future premiums for all policyholders 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 insurer 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 insurer's annual report shall include the insurer's calculation of the dividends and credits applicable to all policy forms, as well as an explanation of the insurer's plan to issue dividends or credits. c. The commissioner shall specify by regulation: (1) any informational filings required to be submitted by insurers to the commissioner in order to determine whether insurers are in compliance with their 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 policyholder; and (4) the instructions and format for submitting annual reports. L.2019, c.358, s.4.

N.J. Stat. § 17B:27-52 Group life and health--package policies

Any insurer authorized to write in this State group life and group health insurance may provide such coverages in one policy or in separate policies, or in supplements or riders to such policy or policies, with or without health insurance benefits on account of families or dependents of the insured employees or members, if the provisions of any such policy, supplement or rider which treat of group life insurance, and the provisions which treat of group health insurance comply respectively with the requirements of the law of this State applicable to the respective forms of insurance. L.1971, c. 144, s. 17B:27-52.

N.J. Stat. § 17B:27-53 Group life and health--rate reductions and application of dividends; excess over employer's cost

If a policy dividend is hereafter declared or a reduction in rate is hereafter made or continued under any group insurance policy heretofore or hereafter issued to an employer, or to a labor union, or to the trustees of a fund established in whole or in part by an employer or a labor union, the excess, if any, of the aggregate dividends or rate reductions under such policy and all other group insurance policies of the policyholder over the aggregate expenditure for insurance under such policies made from funds contributed by the policyholder, or by an employer of insured persons, or by a union or association to which insured persons belong, including expenditures made in connection with administration of such policies, shall be applied by the policyholder for the sole benefit of insured employees or members. L.1971, c. 144, s. 17B:27-53.

N.J. Stat. § 17B:27-54 Application of provisions; definitions.

14. The provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) shall apply to group health insurance coverage that is not subject to the provisions of P.L.1992, c.161 and c.162 (C.17B:27A-2 et seq. and 17B:27A-17 et seq.). To the extent that any provision of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) is inconsistent with the provisions of chapter 27 of Title 17B of the New Jersey Statutes and P.L.1973, c.337 (C.26:2J-1 et seq.), the provisions of sections 14 through 27 shall supersede those laws. As used in sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67): "Affiliation period" means a period which, under the terms of the group health plan offered by a health maintenance organization, begins on the enrollment date and which must expire before the health insurance becomes effective. The health maintenance organization shall not be required to provide health care services or benefits during such period and no premium shall be charged. "Creditable coverage" means, with respect to an individual, coverage of the individual, other than coverage of excepted benefits, under any of the following: a group health plan; health insurance coverage; Part A or Part B of Title XVIII of the federal Social Security Act (42 U.S.C.s.1395 et seq.); Title XIX of the federal Social Security Act (42 U.S.C.s.1396 et seq.); other than coverage consisting solely of benefits under section 1928 of Title XIX of the federal Social Security Act (42 U.S.C.s.1396s); chapter 55 of Title 10, United States Code (10 U.S.C. s.1071 et seq.); a medical care program of the Indian Health Service of a tribal organization; a state health benefits risk pool; a health plan offered under chapter 89 of Title 5, United States Code (5 U.S.C. s.8901 et seq.); a public health plan; and a health benefits plan under section 5(e) of the "Peace Corps Act" (22 U.S.C.s.2504(e)). "Enrollment date" means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for enrollment. "Excepted benefits" means: a. coverage only for accident or disability income insurance, or any combination thereof; coverage issued as a supplement to liability insurance; liability insurance, including general liability insurance and automobile liability insurance; workers' compensation or similar insurance; automobile medical payment insurance; credit-only insurance; coverage for on-site medical clinics; and other similar insurance coverage, as specified by federal regulation, under which benefits for medical care are secondary or incidental to other insurance benefits; b. when provided under a separate policy, certificate or contract of insurance or otherwise not an integral part of the group health plan: limited scope dental or vision benefits, benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof, and such other similar, limited benefits as are specified by federal regulation; c. when offered as independent, noncoordinated benefits: hospital indemnity or other fixed indemnity insurance; d. when offered as a separate insurance policy, certificate or contract of insurance: Medicare supplemental insurance as defined under section 1882(g)(1) of the federal Social Security Act (42 U.S.C. s.1395ss(g)(1)) and coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code (10 U.S.C.s.1071 et seq.) and similar supplemental coverage provided in addition to coverage under a group health plan. "Group health plan" means an employee welfare benefit plan, as defined in Title I of section 3 of Pub.L.93-406, the "Employee Retirement Income Security Act of 1974" (29 U.S.C. s.1002(1)), to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents, as defined under the terms of the plan, directly or through insurance, reimbursement or otherwise. "Health insurance coverage" means benefits consisting of medical care, provided directly, through insurance or reimbursement, or otherwise, and including items and services paid for as medical care, under any hospital or medical expense policy or certificate or health maintenance organization contract offered by a health insurer. "Health insurer" means an insurer licensed to sell health insurance pursuant to Title 17B of the New Jersey Statutes, a health, hospital or medical service corporation, fraternal benefit association or a health maintenance organization. "Health status-related factor" means: health status; medical condition, including both physical and mental illness; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; and disability. "Health maintenance organization" means a federally qualified health maintenance organization as defined in the "Health Maintenance Organization Act of 1973," Pub.L.93-222 (42 U.S.C. s.300e et seq.), an organization authorized under P.L.1973, c.337 (C.26:2J-1 et seq.), or a similar organization regulated under State law for solvency in the same manner and to the same extent as a health maintenance organization authorized to do business in this State. "Late enrollee" means a participant or beneficiary who enrolls in a group health plan other than during: the first period during which the individual is eligible to enroll in the plan; or a special enrollment period. "Medical care" means amounts paid: (1) for the diagnosis, care, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body; and (2) transportation primarily for and essential to medical care referred to in (1) above. "Network plan" means a group health plan offered by a health insurer under which the financing and delivery of medical care, including items and services paid for as medical care, are provided, in whole or in part, through a defined set of providers under contract with the insurer. Network plan includes a health maintenance organization or health insurance company with selective contracting arrangements. "Preexisting condition" means with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for that coverage, whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date. "Waiting period" means with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. L.1997, c.146, s.14; amended 2009, c.293, s.3.

N.J. Stat. § 17B:27-60 Written certification of creditable coverage under COBRA

20. a. A health insurer which offers a group health plan shall provide a written certification of creditable coverage at the time an individual ceases coverage or otherwise becomes covered under a COBRA continuation provision; at the time an individual ceases to be covered under a COBRA continuation provision; and upon request, on behalf of an individual not later than 24 months after the cessation of coverage under the plan or a COBRA continuation provision. b. The written certification of creditable coverage shall include the period of creditable coverage of the individual under the group health plan and the coverage under any COBRA continuation provision and any waiting or affiliation period imposed with respect to the individual for coverage under the plan. L.1997,c.146,s.20.

N.J. Stat. § 17B:27-61 Affiliation period imposed by HMO

21. A health maintenance organization which offers a group health plan and which does not impose a preexisting condition exclusion, may impose an affiliation period if the period is applied uniformly without regard to any health status-related factors and the period does not exceed two months, or three months in the case of a late enrollee. L.1997,c.146,s.21.

N.J. Stat. § 17B:27-62 Permission to enroll for group coverage

22. A health insurer which offers a group health plan shall permit an employee or dependent who is eligible, but not enrolled, for coverage under the terms of the plan, to enroll for coverage if: a. the employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent, and the employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, if the health insurer required such a statement at that time and notified the employee of the insurer s requirements; b. the employee s or dependent s other coverage described in subsection a. of this section was under a COBRA continuation provision and coverage under that provision was exhausted or the coverage was terminated due to loss of eligibility for coverage, including legal separation, divorce, death, termination of employment and reduction in hours of employment, or to the termination of employer contributions toward that coverage; and c. the employee requests enrollment not later than 30 days after exhaustion of coverage under a COBRA continuation provision or termination of coverage pursuant to subsection b. of this section. L.1997,c.146,s.22.

N.J. Stat. § 17B:27-63 Dependent special enrollment period

23. If a group health plan makes coverage available with respect to a dependent of an individual who is a participant under the plan or has satisfied any waiting period and is eligible to be enrolled, and the dependent becomes a dependent of the individual through marriage, birth, adoption or placement for adoption, the group health plan shall provide for a dependent special enrollment period during which the dependent and individual, if necessary, may be enrolled. The dependent special enrollment period shall be for a period of not less than 30 days and shall begin on the later of the date dependent coverage is made available or the date of marriage, birth, adoption or placement for adoption. If an individual enrolls a dependent during the first 30 days of the dependent special enrollment period, the coverage of the dependent shall become effective: in the case of a marriage, no later than the first day of the first month after the date the completed request for enrollment is received; in the case of a dependent s birth, as of the date of birth; and in the case of a dependent s adoption or placement for adoption, the date of the adoption or placement for adoption. L.1997,c.146,s.23.

N.J. Stat. § 17B:27-64 Rules for eligibility, health status-related factors prohibited

24. A health insurer which offers a group health plan may not establish rules for eligibility, including continued eligibility, of any individual to enroll under the terms of the plan based on health status-related factors in relation to the individual or a dependent of the individual. The provisions of this section shall not be construed to require a group health plan to provide particular benefits other than those provided under the terms of its coverage or to prevent the coverage from establishing limitations or restrictions on the amount, level, extent or nature of the benefits or coverage for similarly situated individuals enrolled in the coverage. L.1997,c.146,s.24.

N.J. Stat. § 17B:27-65 Premiums, contributions regulated

25. A health insurer which offers a group health plan may not require an individual, as a condition of enrollment or continued enrollment under the plan, to pay a premium or contribution which is greater than the premium or contribution for a similarly situated enrollee in the plan on the basis of any health status-related factor in relation to the individual or to an enrollee or a dependent of the individual or enrollee. This provision shall not be construed to restrict the amount that an employer may be charged for coverage under a group health plan or to prevent a health insurer offering group health insurance coverage from establishing premium discounts or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention. L.1997,c.146,s.25.

N.J. Stat. § 17B:27-66 Renewal of coverage; exceptions

26. A health insurer which offers health insurance coverage in connection with a group health plan shall renew the coverage under the plan at the option of the policy holder, except that: a. A health insurer may discontinue the coverage only if: (1) the policy holder has failed to pay premiums or contributions in accordance with the terms of the health insurance coverage or the insurer has not received timely premium payments; (2) the policy holder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the health insurance coverage; and (3) in the case of a health insurer which offers a group health plan through a network plan, there is no longer any enrollee in the plan who lives, resides or works in the service area of the insurer or in the area for which the insurer is authorized to do business; or b. A health insurer may not renew the health insurance coverage only if: (1) the policy holder has failed to comply with a material plan provision relating to employer contribution or group participation rules; or (2) the insurer is ceasing to offer coverage in the market in accordance with State and federal law. c. A health insurer may cease offering and not renew a particular type of health insurance coverage only if: (1) the insurer provides notice to each certificate or policy holder who is provided coverage of this type, and to participants and beneficiaries covered under the coverage of the nonrenewal at least 90 days prior to the date of the nonrenewal of the coverage; (2) the insurer offers the option to purchase all or any other health insurance coverage that the insurer offers; and (3) in exercising the option to not renew coverage of a particular type and in offering the option to purchase all or any other health insurance coverage that the insurer offers, the insurer acts uniformly without regard to the claims experience of the certificate or policy holder or any health status-related factor relating to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for the coverage. d. A health insurer may cease offering and not renew all health insurance coverage only if: (1) the insurer provides notice to the Department of Banking and Insurance and each employer and participants and beneficiaries covered under the health insurance coverage, of the nonrenewal at least 180 days prior to the date of the nonrenewal; (2) the insurer ceases offering all health insurance coverage issued or delivered for issuance in the State for groups under the provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67) and coverage under the health insurance coverage is not renewed; and (3) the insurer may not provide for the issuance of any health insurance coverage for groups in this State under the provisions of sections 14 through 27 of P.L.1997, c.146 (C.17B:27-54 through C.17B:27-67), during a five-year period beginning on the termination date of the last health insurance coverage that was not renewed. L.1997,c.146,s.26.

N.J. Stat. § 17B:27-67 Modification of coverage

27. At the time of coverage renewal, a health insurer may modify the health insurance coverage for a product offered to a group health plan. L.1997,c.146,s.27.

N.J. Stat. § 17B:27-68 Conditions for issuance, delivery of group life insurance.

1. Except as provided in section 2 of this act, no policy of group life insurance shall be delivered or issued for delivery in this State unless it meets one of the descriptions in subsections a. through h. of this section: a. A policy issued to an employer, or to the trustees of a fund established by an employer, which employer or trustees shall be deemed the policyholder, to insure employees of the employer for the benefit of persons other than the employer, including the funding of employee benefit plans, subject to the following requirements: (1) The employees eligible for insurance under the policy shall be all of the employees of the employer, or all of any class thereof. The policy may provide that the term "employees" shall include the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control. The policy may provide that the term "employees" shall include the individual proprietor or partners if the employer is an individual proprietorship or partnership. The policy may provide that the term "employees" may include retired employees, former employees and directors of a corporate employer. (2) The premium for the policy shall be remitted by the policyholder either from the employer's funds or from funds contributed by the insured employees, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured employees shall insure all eligible employees, except those who reject the coverage in writing. (3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer. b. A policy issued to a creditor or its parent holding company or to a trustee or agent designated by two or more creditors, which creditor, holding company, affiliate, trustee or agent shall be deemed the policyholder, to insure debtors of the creditor subject to the following requirements: (1) The debtors eligible for insurance under the policy shall be all of the debtors of the creditor, or all of any class thereof. The policy may provide that the term "debtors" shall include: (a) Borrowers of money or purchasers or lessees of goods, services or property for which payment is arranged through a credit transaction; (b) The debtors of one or more subsidiary corporations; and (c) The debtors of one or more affiliated corporations, proprietorships or partnerships if the business of the policyholder and of the affiliated corporations, proprietorships or partnerships is under common control. (2) The premium for the policy shall be remitted by the policyholder either from the creditor's funds, or from charges collected from the insured debtors, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from the funds contributed by insured debtors specifically for their insurance shall insure all eligible debtors. (3) An insurer may exclude any debtors as to whom evidence of individual insurability is not satisfactory to the insurer. (4) The amount of the insurance on the life of any debtor shall at no time exceed the greater of the scheduled or actual amount of unpaid indebtedness to the creditor, except that insurance written in connection with open-end credit having a credit limit exceeding $10,000 may be in an amount not exceeding the credit limit. (5) The insurance may be payable to the creditor or any successor to the right, title and interest of the creditor. The payment shall reduce or extinguish the unpaid indebtedness of the debtor to the extent of the payment and any excess of the insurance shall be payable to the estate of the insured. (6) Notwithstanding the provisions of paragraphs (1) through (5) of this subsection, insurance on agricultural credit transaction commitments may be written up to the amount of the loan commitment on a non-decreasing or level term plan. Insurance on educational credit transactions commitments may be written up to the amount of the loan commitment less the amount of any repayments made on the loan. c. A policy issued to a labor union, or similar employee organization, which shall be deemed to be the policyholder, to insure members of the union or organization for the benefit of persons other than the union or organization or any of its officials, representatives or agents, shall be subject to the following requirements: (1) The members eligible for insurance under the policy shall be all of the members of the union or organization, or all of any class or classes thereof. (2) The premium for the policy shall be remitted by the policyholder either from funds of the union or organization, or from funds contributed by the insured members specifically for their insurance, or from both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured members specifically for their insurance shall insure all eligible members, except those who reject the coverage in writing. (3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer. d. A policy issued to a trust or to the trustees of a fund established or adopted by two or more employers, or by one or more labor unions or similar employee organizations, or by one or more employers and one or more labor unions or similar employee organizations, which trust or trustees shall be deemed the policyholder, to insure employees of the employers or members of the unions or organizations for the benefit of persons other than the employers or the unions or organizations, subject to the following requirements: (1) The persons eligible for insurance shall be all of the employees of the employers or all of the members of the unions or organizations, or all of any class thereof. The policy may provide that the term "employees" shall include the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships or partnerships if the business of the employer and of the affiliated corporations, proprietorships or partnerships is under common control. The policy may provide that the term "employees" shall include the individual proprietor or partners if the employer is an individual proprietorship or partnership. The policy may provide that the term "employees" shall include retired employees, former employees and directors of a corporate employer. The policy may provide that the term "employees" shall include the trustees or their employees, or both, if their duties are principally connected with the trusteeship. (2) The premium for the policy shall be remitted by the policyholder from funds contributed by the employer of the insured persons, or by the union or similar employee organizations, or by both, or from funds contributed by the insured persons or from both the insured persons and the employers or unions or similar employee organizations. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured persons specifically for their insurance shall insure all eligible persons, except those who reject the coverage in writing. (3) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer. e. (1) A policy issued to an association or to a trust or to the trustees of a fund established, created or maintained for the benefit of members of one or more associations. The association shall have at the outset a minimum of 100 persons; shall have been organized and maintained in good faith for purposes other than that of obtaining insurance; shall have been in active existence for at least two years; and shall have a constitution and by-laws which provide that the association hold regular meetings not less than annually to further purposes of the members; except for credit unions, the association, collect dues or solicit contributions from members; and the members have voting privileges and representation on the governing board and committees. (2) The policy shall be subject to the following requirements: (a) The policy may insure members of the association, employees thereof or employees of members, or one or more of the preceding or all of any class thereof for the benefit of persons other than the employee's employer. The policy may provide that the term "employees" may include retired employees, former employees and directors of a corporate member of the association. (b) The premium for the policy shall be remitted by the policyholder from funds contributed by the association, or by employer members, or by both, or from funds contributed by the covered persons or from both the covered persons and the associations, or employer members. (c) Except as provided in subparagraph (d) of this paragraph, a policy on which no part of the premium is to be derived from funds contributed by the covered persons specifically for the insurance shall insure all eligible persons, except those who reject the coverage in writing. (d) An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer. f. A policy issued to a credit union or to a trustee or agent designated by two or more credit unions, which credit union, trustee or agent shall be deemed the policyholder, to insure members of the credit union for the benefit of persons other than the credit union, trustee or agent, or any of their officials, subject to the following requirements: (1) The members eligible for insurance shall be all of the members of the credit union, or all of any class thereof. (2) The premium for the policy shall be remitted by the policyholder from the credit union's funds and, except as provided in paragraph (3) of this section, shall insure all eligible members. (3) An insurer may exclude or limit the coverage on any member as to whom evidence of individual insurability is not satisfactory to the insurer. g. A policy issued to a bank, savings and loan association, or other regulated financial institution or to a trustee or agent designated by two or more such financial institutions, or to a regulated issuer of a credit card, charge card or payment card used to buy goods or services, which shall be deemed policyholders, to insure the depositors, account holders or card holders of such policyholders. Such insurance shall be for the benefit of persons other than the policyholders or any of their officials. The insurance shall be subject to the following requirements: (1) Those eligible for insurance shall be all of the depositors, account holders or card holders of the policyholder, or all of any class or classes thereof. (2) The premium for the policy shall be remitted by the policyholder from funds contributed by the policyholder, or contributed by the insured persons, or contributed by both. Except as provided in paragraph (3) of this subsection, a policy on which no part of the premium is to be derived from funds contributed by the insured persons, shall insure all eligible persons, except those who reject the coverage in writing. (3) An insurer may exclude or limit the coverage on any member as to whom evidence of individual insurability is not satisfactory to the insurer. h. A policy issued to a duly incorporated State Policemen's Benevolent Association or Fraternal Order of Police, which association or order shall be deemed the policyholder, to insure members of the association or order for the benefit of persons other than the association, order or any of its officials, subject to the following requirements: (1) The persons eligible for insurance under the policy shall be all of the members of the association or order or all of any class thereof determined by conditions pertaining to their employment, or the membership in the association, order or both. (2) The premium for the policy shall be remitted by the policyholder wholly from the association's or order's funds. No policy may be issued on which any part of the premium is to be derived from funds contributed by the insured members specifically for their insurance. The policy must insure all eligible members, or all except any as to whom evidence of individual insurability is not satisfactory to the insurer. (3) The policy must cover at least 10 members at date of issue. (4) The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the members or the association or order. L.2005,c.190,s.1.

N.J. Stat. § 17B:27-69 Conditions for issuance, delivery of group life insurance to groups not included in C.17B:27-68.

2. a. Group life insurance offered to a resident of this State under a group life insurance policy issued to a group other than one described in section 1 of this act shall be subject to the requirements of this section. b. A group life insurance policy shall not be delivered or issued for delivery in this State unless the commissioner finds that: (1) The issuance of the group policy is not contrary to the best interest of the public; (2) The issuance of the group policy would result in economies of acquisition or administration; and (3) The benefits are reasonable in relation to the premiums charged. c. Group life insurance coverage may not be offered in this State by an insurer under a policy issued in another state unless this State or another state having requirements substantially similar to those included in paragraphs (1), (2) and (3) of subsection b. of this section has made a determination that those requirements have been met. d. The premium for the policy shall be remitted by the policyholder either from the policyholder's funds or from funds contributed by the covered persons, or from both. e. An insurer may exclude or limit the coverage on any person as to whom evidence of individual insurability is not satisfactory to the insurer. L.2005,c.190,s.2.

N.J. Stat. § 17B:27-70 Written notice to prospective insureds of noncompliance with C.17B:27-68; definitions.

3. a. With respect to a program of insurance which, if issued on a group basis, does not meet the requirements of section 1 of this act, the insurer shall cause to be distributed to prospective insureds a written notice that compensation shall or may be paid, if compensation of any kind shall or may be paid to: (1) A policyholder or sponsoring or endorsing entity in the case of a group policy; or (2) A sponsoring or endorsing entity in the case of individual, blanket or franchise policies marketed by means of direct response solicitation. b. The notice shall be distributed: (1) Whether compensation is direct or indirect; and (2) Whether the compensation is paid to or retained by the policyholder or sponsoring or endorsing entity, or paid to or retained by a third party at the direction of the policyholder or sponsoring or endorsing entity, or an entity affiliated therewith by way of ownership, contract or employment. c. The notice required by this section shall be placed on or accompany an application or enrollment form provided to prospective insureds. d. For the purposes of this section: (1) "Direct response solicitation" means a solicitation through a sponsoring or endorsing entity through the mails, telephone or other mass communications media; and (2) "Sponsoring or endorsing entity" means an organization that has arranged for the offering of a program of insurance in a manner that communicates that eligibility for participation in the program is dependent upon affiliation with the organization or that it encourages participation in the program. L.2005,c.190,s.3.

N.J. Stat. § 17B:27-71 Extension to dependents of group life insurance policy.

4. Except for a policy issued under subsection b. of section 1 of this act, a group life insurance policy may be extended to insure the employees or members against loss due to the death of their spouses, domestic partners and dependent children, and any other persons dependent upon the insured employees or members, or any class thereof, subject to the following: a. The premium for the insurance shall be remitted by the policyholder either from funds contributed by the employer, union, association or other person to whom the policy has been issued, or from funds contributed by the covered persons, or from both. Except as provided in subsection b. of section 1 of this act, a policy on which no part of the premium for the spouse's, domestic partner's, dependent child's and other dependent's coverage is to be derived from funds contributed by the covered persons shall insure all eligible employees or members with respect to their spouses, domestic partners, dependent children and other dependents, or any class thereof. b. An insurer may exclude or limit the coverage on any spouse, domestic partner, dependent child or any other person dependent upon the insured employee or member as to whom evidence of individual insurability is not satisfactory to the insurer. c. The amounts of insurance for any covered spouse, domestic partner, dependent child or any other person dependent upon the insured employee or member under the policy may not exceed 100% of the amount of insurance for which the employee or member is insured. L.2005,c.190,s.4.

N.J. Stat. § 17B:27-72 Required provisions for delivery, issuance of group life insurance policy.

5. a. No policy of group life insurance shall be delivered or issued for delivery in this State unless it contains in substance the following provisions, or provisions which in the opinion of the Commissioner of Banking and Insurance are more favorable to the persons insured, or at least as favorable to the persons insured and more favorable to the policyholder. However, subsections g. through l. of this section shall not apply to policies insuring the lives of debtors; the standard provisions required for individual life insurance policies shall not apply to group life insurance policies; and if the group life insurance policy is on a plan of insurance other than the term plan, it shall contain a nonforfeiture provision which, in the opinion of the commissioner, is equitable to the insured persons and to the policyholder. Nothing herein shall be construed to require that group life insurance policies contain the same nonforfeiture provisions as are required for individual life insurance policies. b. The policy shall contain a provision that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the death benefit coverage shall continue in force, unless the policyholder gives the insurer written notice of discontinuance in advance of the date of discontinuance and in accordance with the terms of the policy. The policy may provide that the policyholder shall be liable to the insurer for the payment of a pro rata premium for the time the policy was in force during the grace period. c. The policy shall contain a provision that the validity of the policy shall not be contested except for nonpayment of premiums after it has been in force for two years from its date of issue; and that no statement made by any person insured under the policy relating to the person's insurability shall be used in contesting the validity of the insurance with respect to which the statement was made after the insurance has been in force prior to the contest for a period of two years during the person's lifetime or unless it is contained in a written instrument signed by the person. d. The policy shall contain a provision that a copy of the application of the policyholder, if any, shall be attached to the policy when issued, that all statements made by the policyholder or by the persons insured shall be deemed representations and not warranties, and that no statement made by any person insured shall be used in any contest unless a copy of the instrument containing the statement is or has been furnished to the person or, in the event of death or incapacity of the insured person, to the insured person's beneficiary or personal representative. e. The policy shall contain a provision setting forth the conditions, if any, under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of his coverage. f. The policy shall contain a provision specifying an equitable adjustment of premiums or benefits, or both, to be made in the event the age of a person insured has been misstated. The provision shall contain a clear statement of the method of adjustment to be made. g. The policy shall contain a provision that any sum becoming due by reason of the death of the person insured shall be payable to the beneficiary designated by the person insured, except that, where the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms, subject to the provisions of the policy in the event there is no designated beneficiary, as to all or any part of the sum, living at the death of the person insured, and subject to any right reserved by the insurer in the policy and set forth in the certificate to pay at its option a part of the sum not exceeding $2,000 to any person appearing to the insurer to be equitably entitled to it by reason of having incurred funeral or other expenses incident to the last illness or death of the person insured. h. The policy shall contain a provision that the insurer will issue to the policyholder, for delivery to each person insured, a certificate setting forth a statement as to the insurance protection to which the person is entitled, to whom the insurance benefits are payable, a statement as to any dependent's coverage included in the certificate, and the rights and conditions set forth in subsections i., j., k., and l. of this subsection. i. The policy shall contain a provision that, if the insurance, or any portion of it, on a person covered under the policy or on the dependent of a person covered, ceases because of termination of employment or of membership in the class eligible for coverage under the policy or change to a class eligible for a smaller amount of insurance, the person shall be entitled to have issued to him by the insurer, without evidence of insurability, an individual policy of life insurance without disability or other supplementary benefits, provided application for the individual policy shall be made, and the first premium paid to the insurer, within 31 days after termination and provided further that: (1) The individual policy shall, at the option of the person, be on any one of the forms then customarily issued by the insurer at the age and for the amount applied for, except that the group policy may exclude the option to elect term insurance; (2) The individual policy shall be in an amount not in excess of the amount of life insurance that ceases because of termination, less the amount of any life insurance for which the person becomes eligible under the same or any other group policy within 31 days after termination, provided that any amount of insurance that shall have matured on or before the date of termination as an endowment payable to the person insured, whether in one sum or in installments or in the form of an annuity, shall not, for the purposes of this provision, be included in the amount that is considered to cease because of termination; and (3) The premium on the individual policy shall be at the insurer's then customary rate applicable to the form and amount of the individual policy, to the class of risk to which the person then belongs, and to the individual age attained on the effective date of the individual policy. Subject to the conditions established in paragraphs (1) and (2) of this subsection, the conversion privilege shall be available: (a) To a surviving dependent, if any, at the death of the employee or member, with respect to the coverage under the group policy that terminates by reason of the death; and (b) To the dependent of the employee or member upon termination of coverage of the dependent, while the employee or member remains insured under the group policy, by reason of the dependent ceasing to be a qualified family member under the group policy. j. The policy shall contain a provision that if the group policy terminates or is amended so as to terminate the insurance of any class of insured persons, every person insured thereunder at the date of termination whose insurance terminates, including the insured dependent of a covered person, and who has been so insured under a group policy for at least five years prior to the termination date, shall be entitled to have issued by the insurer an individual policy of life insurance, subject to the same conditions and limitations as are provided by subsection i. of this section, except that the group policy may provide that the amount of the individual policy shall not exceed the smaller of: (1) The amount of the person's life insurance protection ceasing because of the termination or amendment of the group policy, less the amount of any life insurance for which the person is or becomes eligible under a group policy issued or reinstated by the same or another insurer within 31 days after termination; or (2) $10,000. k. The policy shall contain a provision that, if a person insured under the group policy, or the insured dependent of a covered person, dies during the period within which the individual would have been entitled to have an individual policy issued in accordance with subsection i. or j. of this section and before the individual policy shall have become effective, the amount of life insurance which he would have been entitled to have issued under the individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor had been made. l. Where active employment is a condition of insurance, the policy shall contain a provision that an insured may continue coverage during the insured's total disability by timely payment to the policyholder of that portion, if any, of the premium that would have been required from the insured had total disability not occurred. The continuation shall be on a premium paying basis for a period of six months from the date on which the total disability started, but not beyond the earlier of: (1) Approval by the insurer of continuation of the coverage under any disability provision which the group insurance policy may contain; or (2) The discontinuance of the group insurance policy. m. In the case of a policy insuring the lives of debtors, the policy shall contain a provision that the insurer shall furnish to the policyholder for delivery to each debtor insured under the policy a certificate of insurance describing the coverage and specifying that the death benefit shall first be applied to reduce or extinguish the indebtedness. n. In participating policies, there shall be a provision that the policy shall participate in the divisible surplus of the insurer as determined by the insurer and that the insurer shall determine annually the extent of such participation, if any; and that the policyholder shall have the right to any dividend arising from the participation paid in cash unless another dividend option contained in the policy has been elected. o. In the case of a policy which provides that each insured debtor whose protection under the group insurance policy terminates by reason of absolute assignment by the creditor of the insured debtor's indebtedness for the discharge of which the debtor had agreed upon installment payments over a period of more than 10 years, there shall be a provision that each insured debtor shall be entitled to have issued to him by the insurer, without evidence of insurability, upon application made to the insurer and upon the payment of the premium applicable to the class of risk to which he belongs and to the form and amount of the policy at his then attained age within 31 days after that assignment of the indebtedness, an individual policy of life insurance; provided, the individual policy of life insurance so issued shall be in any one of the level premium forms customarily issued by the insurer, except term insurance, in an amount equal to the amount of his protection terminated under the group insurance policy because of the assignment, less the amount of insurance for which the insured debtor may become eligible and qualify under any group insurance policy in effect with the assignee at the date of the assignment or issued to the assignee within that period of 31 days; and provided further, that in the event that the assignment of the indebtedness shall have been made by the creditor at the request of the insured debtor, the insurer may require satisfactory evidence of the debtor's insurability before making the individual policy of life insurance effective. If the insured debtor dies during the period within which he would have been entitled to have an individual policy issued to him in accordance with this provision and before such an individual policy shall have become effective, the amount of life insurance which he would have been entitled to have issued to him under that individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor has been made. L.2005,c.190,s.5.

N.J. Stat. § 17B:27-73 Issuance, delivery of individual policy of life insurance.

6. If an individual insured under a group insurance policy hereafter delivered or issued for delivery in this State becomes entitled under the terms of the policy to have an individual policy of life insurance issued without evidence of insurability, subject to making application and payment of the first premium within the period specified in the policy, and if the individual is not given notice of the existence of the right at least 15 days prior to the expiration date of the period, then the individual shall have an additional period within which to exercise the right, but nothing herein contained shall be construed to continue any insurance beyond the period provided in the policy. This additional period shall expire 15 days after the individual is given notice but in no event shall the additional period extend beyond 60 days after the expiration date of the period provided in the policy. Written notice presented to the individual or mailed by the policyholder to the last known address of the individual or mailed by the insurer to the last known address of the individual as furnished by the policyholder shall constitute notice for the purpose of this section. L.2005,c.190,s.6.

N.J. Stat. § 17B:27-74 Filing of form required for delivery, issuance of group life insurance.

7. a. No group life insurance policy, or application, if a written application is required and is to be made a part of the policy, certificate, printed rider or endorsement for use with the policy, shall be delivered or issued for delivery in this State unless the form has been filed with the Commissioner of Banking and Insurance for approval in accordance with the provisions of section 16 of P.L.1995, c.73 (C.17B:25-18.2). b. If a form is disapproved for filing by the commissioner during the 60-day period provided in section 16 of P.L.1995, c.73 (C.17B:25-18.2), it may not be delivered or issued for delivery unless it is resubmitted and approved in accordance with the provisions of subsections b., c., and d., of section 16 of P.L.1995, c.73 (C.17B:25-18.2). Such disapproval shall be subject to review in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.). c. Any 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.), becomes final in accordance therewith. d. This section shall not apply to documents which relate only to the manner of distribution of benefits or to the reservation of rights and benefits under group life insurance policies and which are used at the request of the individual insured or policyholder. e. The disapproval by the commissioner of any form may be on the grounds that the form contains provisions which are unjust, unfair, inequitable, misleading, or contrary to law or to the public policy of this State. L.2005,c.190,s.7.

N.J. Stat. § 17B:27-75 Payment of benefits.

8. a. Notwithstanding any policy provision to the contrary, benefits under a group life insurance policy subject to this act shall become payable by reason of the death of the insured within 60 days after the receipt of due proof of death and, at the insurer's option, proof of the interest of the claimant. b. If a claim or a portion of a claim for benefits under a policy requires additional investigation or is denied by the insurer, the claimant shall be notified in writing no later than 45 days following receipt by the insurer of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy, that the claim, or a portion thereof, is subject to additional investigation or denied, and the reason the claim is being investigated or denied. Notwithstanding the provisions of this subsection b. to the contrary, the notice to the claimant for any claim which the insurer concludes, based upon its investigation and which conclusion is reasonably based upon the contents of the insurer's claim file, constitutes probable cause for fraud shall not be required to contain the specific reasons for the investigation. A conclusion of fraud that is not reasonably based upon the contents of the insurer's claim file shall be a violation of section 1 of P.L.1975, c.101 (C.17B:30-13.1), notwithstanding that the violation did not occur with such frequency as to indicate a general business practice. Any uncontested portion of a claim shall be paid no later than 60 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer under the terms of the policy. c. The insurer, upon receipt of any document or information requested relating to a claim or portion of a claim under investigation, shall pay the benefits for which the claim is made, or deny the claim no later than 90 days following the receipt of the document or information. d. Payment of a claim or a portion thereof that is not under investigation by the insurer shall be overdue if not remitted to the claimant by the insurer on or before 60 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer pursuant to the policy. Payment of a claim, or a portion of a claim under investigation, or denied, that becomes eligible for payment shall be overdue if not remitted to the claimant by the insurer on or before 90 days following receipt of due proof of death, proof of the interest of the claimant, or any other document or information requested by the insurer. Overdue payments shall bear an annual rate of interest equal to the average rate of return of the State of New Jersey Cash Management Fund, established pursuant to section 1 of P.L.1977, c.281 (C.52:18A-90.4), for the preceding fiscal year, rounded to the nearest one-half percent. L.2005,c.190,s.8.

Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.njleg.state.nj.us/legislative-activity/statutesFetched: 10/17/2026