New_jersey Statute | Act | Code |Title 17b Insurance| US Code - US Statute

17B:26-2. Form of policy; requirements a. No such policy of insurance shall be delivered or issued for delivery to any person in this State unless: (1) The entire money and other considerations therefor are expressed therein; and (2) The time at which the insurance takes effect and terminates is expressed therein; and (3) It purports to insure only one person, except that a policy may insure, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyholder, any two or more eligible members of that family, including husband, wife, dependent children or any children under a specified age which shall not exceed 19 years and any other person dependent upon the policyholder; and (4) The style, arrangement and over-all appearance of the policy give no undue prominence to any portion of the text, and unless every printed portion of the text of the policy and of any endorsements or attached papers is plainly printed in light-faced type of a style in general use, the size of which shall be uniform and not less than 10-point with a lower-case unspaced alphabet length not less than 120-point (the ~text~ shall include all printed matter except the name and address of the insurer, name or title of the policy, the brief description if any, and captions and subcaptions); and (5) The exceptions and reductions of indemnity are set forth in the policy and, except those which are set forth in sections 17B:26-3 to 17B:26-31 inclusive, are printed, at the insurer@s option, either included with the benefit provision to which they apply, or under an appropriate caption such as ~exceptions,~ or ~exceptions and reductions,~ provided that if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies; and (6) Each such form, including riders and endorsements, shall be identified by a form number in the lower left-hand corner of the first page thereof; and (7) It contains no provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless such portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the commissioner. b. A policy under which coverage of a dependent of the policyholder 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 mental retardation or physical handicap and who became so incapable prior to attainment of age 19 and who is chiefly dependent upon such policyholder for support and maintenance, not so terminate while the policy remains in force and the dependent remains in such condition, if the policyholder has within 31 days of such dependent@s attainment of the limiting age submitted proof of such dependent@s incapacity as described herein. The foregoing provisions of this paragraph shall not require an insurer to insure a dependent who is a mentally retarded or physically handicapped child where the policy is underwritten on evidence of insurability based on health factors set forth in the application or where such dependent does not satisfy the conditions of the policy as to any requirement for evidence of insurability or other provisions of the policy, satisfaction of which is 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. c. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any optometric service which is within the lawful scope of practice of a duly licensed optometrist, the insured under such policy shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed optometrist. d. If any policy is issued by an insurer domiciled in this State for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state shall have advised the commissioner that any such policy is not subject to approval or disapproval by such official, the commissioner may by ruling require that such policy meet the standards set forth in subsection a. of this section and in sections 17B:26-3 to 17B:26-31 inclusive. e. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any psychological service which is within the lawful scope of practice of a duly licensed psychologist, the insured under such policy shall be entitled to reimbursement for such service, whether the said service is performed by a physician or duly licensed psychologist. f. Notwithstanding any provision of a policy of health insurance, hereafter delivered or issued for delivery in this State, whenever such policy provides for reimbursement for any service which is within the lawful scope of practice of a duly licensed chiropractor, the insured under such policy 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. g. All individual health insurance policies which provide coverage for a family member or dependent of the insured on an expense incurred basis shall also provide that the health insurance benefits applicable for children shall be payable with respect to a newly born child of that insured from the moment of birth. (1) 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. (2) 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 31 days after the date of birth in order to have the coverage continue beyond such 31-day period. h. All individual health insurance policies which provide coverage on an expense incurred basis but do not provide coverage for a family member or dependent of the insured on an expense incurred basis 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 therefor and payment of the required premium are made to the insurer to include in said policy coverage the same or similar to that of the insured, described in g. (1) above 31 days from the date of a newborn child. i. Whenever, pursuant to the provisions of an individual or group contract issued by an insurer, the former spouse of a named insured is no longer entitled to coverage as an individual dependent by reason of divorce, separate coverage for such former spouse shall be made available by the insurer on an individual non-group basis under the following conditions: (1) Application for such non-group coverage shall be made to the insurer by or on behalf of such former spouse no later than 31 days following the date his or her coverage under the prior certificate or contract terminated. (2) No new evidence of insurability shall be required in connection with the application for such non-group coverage but any health exception, limitation or exclusion applicable to said former spouse under the prior coverage may, at the option of the insurer, be carried over to the new non-group coverage. (3) The effective date of the new coverage shall be the day following the date on which such former spouse@s coverage under the prior certificate or contract terminated. (4) The benefits provided under the non-group coverage issued to such former spouse shall be at least equal to the basic benefits provided in contracts then being issued by the insurer to acceptable new non-group applicants of the same age and family status. L.1971, c. 144, s. 17B:26-2. Amended by L.1973, c. 22, s. 14, eff. Feb. 8, 1973; L.1973, c. 342, s. 1, eff. Dec. 27, 1973; L.1975, c. 111, s. 1; L.1975, c. 119, s. 1, eff. June 5, 1975; L.1979, c. 86, s. 5, eff. May 15, 1979; L.1980, c. 113, s. 2, eff. Sept. 19, 1980. 17B:26-2.1. Treatment of alcoholism; benefits No health insurance contract providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Insurance after the effective date of this act, unless such contract provides benefits to any subscriber or other person covered thereunder for expenses incurred in connection with the treatment of alcoholism when such treatment is prescribed by a doctor of medicine. Such benefits shall be provided to the same extent as for any other sickness under the contract. Every contract shall include such benefits for the treatment of alcoholism as are hereinafter set forth: a. Inpatient or outpatient care in a licensed hospital; b. Treatment at a detoxification facility licensed pursuant to P.L.1975, c. 305; c. Confinement as an inpatient or outpatient at a licensed, certified, or state approved residential treatment facility, under a program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation. Treatment or confinement at any facility shall not preclude further or additional treatment at any other eligible facility; provided, however, that the benefit days used do not exceed the total number of benefit days provided for any other sickness under the contract. L.1977, c. 118, s. 1, eff. June 2, 1977. 17B:26-2.1a. Reconstructive breast surgery; benefits 1. Every 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.53,s.1; amended 1997, c.75, s.4. 17B:26-2.1b. Health insurance policies Every 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 coverage for the expenses of pregnancy and childbirth shall be provided to the same extent as the hospitalization benefits are 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. 275, s. 2. 17B:26-2.1c. Benefits for equipment for home treatment of hemophilia Every 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. 64, s. 1. 17B:26-2.1d. Individual health insurance policy to pay benefits for treatment of Wilm@s tumor Every individual 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.4. 17B:26-2.1e Individual health insurance policy, mammogram examination benefits. 4. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, unless the policy provides benefits to any named insured or other person covered thereunder for expenses incurred in conducting: one baseline mammogram examination for women who are at least 35 but less than 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. These 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. L.1991,c.279,s.4; amended 1999, c.341, s.4; 2004, c.86, s.4. 17B:26-2.1f. Individual health insurance benefits for certain nursing services 1. a. Notwithstanding any provision of a policy of individual 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 service so performed, a person covered under that individual 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 26 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 individual 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 has reserved the right to change the premium. L.1992,c.128,s.1. 17B:26-2.1g. Individual health insurance policy, benefits for ~off-label~ drugs required 5. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et al.), no individual 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 type of 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 a treatment approved by the Food and Drug Administration. c. This section shall apply to all individual 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.5. 17B:26-2.1h. Individual health insurer, benefits for health promotion 6. a. Every individual policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of 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 every two years; (6) For all women 40 years of age or older, a mammogram examination pursuant to the provisions of section 4 of P.L.1991, c.279 (C.17B:26-2.1e); (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 individual 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. of this section in an amount which shall not exceed: $125 a year for each person between the ages of 20 to 39, inclusive; $145 a year for each man age 40 and over; and $235 a year for each woman age 40 and over; except that for persons 45 years of age or older, the cost of a left-sided colon examination shall not be included in the above amount; however, no 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 individual 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.6; amended 1999, c.339, s.4. 17B:26-2.1i Requirements for individual health insurer providing benefits for pharmacy services. 4. a. Notwithstanding any other provision of law to the contrary, no individual 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 individual health insurance policies in which the insurer has reserved the right to change the premium. L.1993,c.378,s.4; amended 1999, c.395, s.4. 17B:26-2.1j. Benefits for certain cancer treatments 4. In addition to benefits provided under regulations adopted pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), an insurer shall offer under every individual 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.4. 17B:26-2.1k. Coverage for birth and natal care; health insurance policy 4. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act shall provide coverage for a minimum of 48 hours of in-patient care following a vaginal delivery and a minimum of 96 hours of in-patient care following a cesarean section for a mother and her newly born child in a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.). The provisions of this section shall apply to all 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.4. 17B:26-2.1l. Coverage for diabetes treatment by individual health insurance policy 4. a. Every individual health insurance policy providing hospital or medical expense benefits that is delivered, issued, executed or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of 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. b. Each individual 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 individual 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 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.4. 17B:26-2.1m. Coverage for minimum inpatient care following mastectomy by individual hospital, medical expense benefits policy 4. a. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act shall provide coverage for a minimum of 72 hours of inpatient care following a modified radical mastectomy and a minimum of 48 hours of inpatient care following a simple mastectomy. The 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.4. 17B:26-2.1n Applicability of Health Care Quality Act 21. Notwithstanding the provisions of chapter 26 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.21. 17B:26-2.1o Coverage for treatment of inherited metabolic diseases by individual health insurance policy. 4. No individual health insurance policy providing hospital or medical expense benefits shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, unless the policy provides benefits to 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.4. 17B:26-2.1p Health insurance policy to cover certain audiology, speech-language pathology services. 4. Notwithstanding any other provision of chapter 26 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 26 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.4. 17B:26-2.1q Coverage for treatment of domestic violence injuries by individual health insurance policy. 4. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.), no individual 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.4. 17B:26-2.1r. Coverage for certain dental procedures for the severely disabled or child age five or under by individual health insurance policy 4. a. No individual health insurance policy providing hospital or medical benefits shall be delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this 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. An individual 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 individual health insurance policies in which the insurer has reserved the right to change the premium. L.1999,c.49,s.4. 17B:26-2.1s Individual health insurers to provide coverage for biologically-based mental illness. 4. a. Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to chapter 26 of Title 17B of the New Jersey Statutes, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act shall provide coverage for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the contract. ~Biologically-based mental illness~ means a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant or psychological syndrome or pattern that substantially limits the functioning of the person with the illness, including but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism. ~Same terms and conditions~ means that the insurer cannot apply different copayments, deductibles or benefit limits to biologically-based mental health benefits than those applied to other medical or surgical benefits. b. Nothing in this section shall be construed to change the manner in which the insurer determines: (1) whether a mental health care service meets the medical necessity standard as established by the insurer; or (2) which providers shall be entitled to reimbursement for providing services for mental illness 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.1999,c.106,s.4. 17B:26-2.1t. Coverage for hemophilia services by individual health insurers 3. Notwithstanding the provisions of chapter 26 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.3. 17B:26-2.1u Individual policy to provide coverage for colorectal cancer screening. 4. Every individual policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any named insured or other person covered thereunder for expenses incurred in conducting colorectal cancer screening at regular intervals for persons age 50 and over and for persons of any age who are considered to be at high risk for colorectal cancer. The methods of screening for which benefits shall be provided shall include: a screening fecal occult blood test, flexible sigmoidoscopy, colonoscopy, barium enema, or any combination thereof; or the most reliable, medically recognized screening test available. The method and frequency of screening to be utilized shall be in accordance with the most recent published guidelines of the American Cancer Society and as determined medically necessary by the covered person@s physician, in consultation with the covered person. As used in this section, ~high risk for colorectal cancer~ means a person has: a. a family history of: familial adenomatous polyposis; hereditary non-polyposis colon cancer; or breast, ovarian, endometrial or colon cancer or polyps; b. chronic inflammatory bowel disease; or c. a background, ethnicity or lifestyle that the physician believes puts the person at elevated risk for colorectal cancer. 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 health insurance policies in which the insurer has reserved the right to change the premium. L.2001,c.295,s.4. 17B:26-2.1v Individual health insurer prescription drug plans to cover certain infant formulas. 5. An individual 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.5. 17B:26-2.1w Policy issued under Chapter 26 of Title 17B required to cover certain out-of-network services. 3. Notwithstanding the provisions of chapter 26 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.365,s.3. 17B:26-2.1x Individual health insurer to offer coverage for domestic partner. 50. An individual 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.50. 17B:26-2.1y Individual health insurer, coverage for prescription female contraceptives. 5. An individual health insurer that provides hospital or medical expense benefits for expenses incurred in the purchase of outpatient prescription drugs under a policy shall provide coverage under every such 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. For the purposes of this section, ~prescription female contraceptives~ means any drug or device used for contraception by a female, which is approved by the federal Food and Drug Administration for that purpose, that can only be purchased in this State with a prescription written by a health care professional licensed or authorized to write prescriptions, and includes, but is not limited to, birth control pills and diaphragms. A religious employer may request, and an insurer shall grant, an exclusion under the policy for the coverage required by this section if the required coverage conflicts with the religious employer@s bona fide religious beliefs and practices. A religious employer that obtains such an exclusion shall provide written notice thereof to prospective insureds and insureds. The provisions of this section shall not be construed as authorizing an insurer to exclude coverage for prescription drugs that are prescribed for reasons other than contraceptive purposes or for prescription female contraceptives that are necessary to preserve the life or health of an insured. For the purposes of this section, ~religious employer~ means an employer that is a church, convention or association of churches or an elementary or secondary school that is controlled, operated or principally supported by a church or by 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). The benefits shall be provided to the same extent as for any other outpatient prescription drug under the policy. This section shall apply to those policies in which the insurer has reserved the right to change the premium. L.2005,c.251,s.5. 17B:26-2.2. 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 examinations 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. 328, s. 1. 17B:26-2.3. Policy benefits for second surgical opinion Any insurer issuing an individual insurance policy in accordance with chapter 26 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 under the policy benefits for a second surgical opinion for elective surgical procedures which would require inpatient admission to a hospital. L.1979, c. 328, s. 2. 17B:26-2.4. Benefit payments Benefits for a second surgical opinion shall include 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 individual policy or, at the insurer@s option, as an additional benefit offered to the prospective policyholder at issue of a policy. Benefit payments may be limited to second surgical opinion services of eligible physicians who have agreed to participate in an insurer@s second surgical opinion program. The benefits shall be reasonably related to amounts payable under the policy for covered surgical procedures. L.1979, c. 328, s. 3. 17B:26-2.5. Third surgical opinion If a second surgical opinion does not confirm that a proposed elective surgical procedure is medically advisable, benefits must be provided under the policy for a third surgical opinion in the same manner as for the second opinion. L.1979, c. 328, s. 4. 17B:26-2.6. Excluded surgical procedures The second surgical opinion benefit provisions of a policy may exclude benefits while the patient is confined in a hospital as an inpatient, any surgical procedures not covered by the policy and surgical procedures in the following categories: cosmetic surgery, dental surgery, and podiatric surgery. L. 1979, c. 328, s. 5. Amended by L. 1985, c. 275, s. 1. 17B:26-2.7. Payment for opinion services of physician If a physician who furnishes a second or third surgical opinion also performs the surgical procedure, the policy need not provide payment for the second or third opinion services of that physician. L.1979, c. 328, s. 6. 17B:26-2.8. 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. 328, s. 7.

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