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

17B:27A-19a. Small employer carrier, offering of high deductible plan. 17. A small employer carrier, as a condition of transacting business in this State, may offer, on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), a health benefits plan pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) 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), if that health benefits plan is offered to an eligible small employer that: a. is a policy or contract holder prior to and on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify 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); b. is not a policy or contract holder on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.) under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) which does not qualify 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) for a period of five years; or c. was not a policy or contract holder under a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) prior to the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.). L.2005,c.248,s.17. 17B:27A-19.1. Hospital confinement, other supplemental limited benefit insurance plans; requirements 10. a. A carrier shall not deliver or issue for delivery a hospital confinement or other supplemental limited benefit insurance plan unless the applicant for such coverage signs a statement on the application form that confirms that the applicant is already covered under a health benefits plan contract or policy. The application form shall be filed with the board on an informational basis. b. A hospital confinement plan or other supplemental limited benefit insurance plan issued to a small employer or other group health benefits plan provider or to individual employees of a small employer or other group health benefits provider: (1) shall be subject to the same rating requirements that apply to health benefits plans issued pursuant to paragraph (2) of subsection a. of section 9 of P.L.1992, c.162 (C.17B:27A-25), except that a hospital confinement plan and supplemental limited benefit insurance plan shall be subject to the commissioner@s exclusive review and regulation with regard to loss ratios, medical underwriting and eligibility requirements, and form approval; and (2) may include preexisting condition exclusions. c. A health benefits plan shall not coordinate benefits against any hospital confinement or other supplemental limited benefit insurance plan. L.1994,c.11,s.10. 17B:27A-19.2 Coverage for birth and natal care; small employer health policy. 6. a. Every policy that provides maternity benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 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.6. 17B:27A-19.3. Regulations governing rating methodology, calculation of loss ratios 7. The commissioner, in consultation with the board, shall establish regulations governing the applicable rating methodology and manner in which loss ratios shall be calculated for health benefits plans permitted to be renewed or continued pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19). In establishing these regulations, the commissioner may consider, but shall not be limited to, the impact of allowing these health benefits plans to continue to be rated separately from the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and on their own claims experience. If the commissioner determines that the continuation of separate rating pools adversely affects the small employer insurance market and serves to counter the public policy goals which led to the enactment of P.L.1992, c.162 (C.17B:27A-17 et seq.), the commissioner shall develop a methodology which creates a linkage between the standard health benefits plans established pursuant to subsection a. of section 3 of P.L.1992, c.162 (C.17B:27A-19) and the plans permitted to be continued or renewed pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) for the purpose of rating and loss ratio calculation. Regulations established under the provisions of this section shall detail all additional obligations of carriers continuing or renewing health benefits plans pursuant to the provisions of subsection j. of section 3 of P.L.1992, c.162 (C.17B:27A-19) which are necessary to meet the general requirements of P.L.1992, c.162 (C.17B:27A-17 et seq.). The regulations shall be adopted pursuant to the ~Administrative Procedure Act,~ P.L.1968, c.410 (C.52:14B-1 et seq.) no later than 180 days following the effective date of this act. Until such time as the regulations are adopted, the health benefits plans shall continue to be rated and subject to the loss ratio calculations in accordance with applicable law in effect on the effective date of P.L.1995, c.340. L.1995,c.340,s.7. 17B:27A-19.4. Coverage for minimum inpatient care following mastectomy by small employer health benefits plan 7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State 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 health benefits plan shall not require a health care provider to obtain authorization from the carrier 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 carrier under the health benefits plan. The benefits shall be provided to the same extent as for any other sickness under the health benefits plan. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium. b. The New Jersey Small Employer Health Benefits Program Board 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.7. 17B:27A-19.5 Applicability of Health Care Quality Act 23. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract 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 or contracts in which the carrier has reserved the right to change the premium. L.1997,c.192,s.23. 17B:27A-19.6 Coverage for treatment of inherited metabolic diseases by small employer health benefits plan. 7. No small employer health benefits plan subject to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) 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 health benefits plan 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 health benefits plan. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium. L.1997,c.338,s.7. 17B:27A-19.7 Small employer health benefits plan to provide coverage for biologically-based mental illness. 7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State on or after the effective date of this act shall provide benefits for biologically-based mental illness under the same terms and conditions as provided for any other sickness under the health benefits plan. ~ 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 plan 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 carrier determines: (1) whether a mental health care service meets the medical necessity standard as established by the carrier; or (2) which providers shall be entitled to reimbursement for providing services for mental illness under the health benefits plan. c. The provisions of this section shall apply to all health benefits plans in which the carrier has reserved the right to change the premium. L.1999,c.106,s.7. 17B:27A-19.8. Coverage for hemophilia services by small employer plan 5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract 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 or contract 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 or contracts in which the carrier has reserved the right to change the premium. L.2000,c.121,s.5. 17B:27A-19.9 Small employer health benefits plan to provide coverage for colorectal cancer screening. 7. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State on or after the effective date of this act, shall provide benefits to any 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 health benefits plan. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium. L.2001,c.295,s.7. 17B:27A-19.10 Policy, contract issued under C.17B:27A-17 et seq. required to cover certain out-of-network services. 5. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of this act unless the policy or contract 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 or contracts in which the carrier has reserved the right to change the premium. L.2001,c.365,s.5. 17B:27A-19.11 Carrier offering plans pursuant to C.17B:27A-17 et seq. may offer additional plan with certain limited benefits. 5. In addition to the five health benefits plans offered by a carrier on the effective date of this act, a carrier that writes small employer health benefits plans pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) may also offer one or more of the plans through the carrier@s network of providers, with no reimbursement for any out-of-network benefits other than emergency care, urgent care, and continuity of care. A carrier@s network of providers shall be subject to review and approval or disapproval by the Commissioner of Banking and Insurance, in consultation with the Commissioner of Health and Senior Services, pursuant to regulations promulgated by the Department of Banking and Insurance, including review and approval or disapproval before plans with benefits provided through a carrier@s network of providers pursuant to this section may be offered by the carrier. Policies or contracts written on this basis shall be rated in a separate rating pool for the purposes of establishing a premium, but for the purpose of determining a carrier@s losses, these policies or contracts shall be aggregated with the losses on the carrier@s other business written pursuant to the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.). L.2001,c.365,s.5. 17B:27A-19.12 Small employer health benefits plan to offer coverage for domestic partner. 54. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State 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). The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium. L.2003,c.246,s.54. 17B:27A-19.13 Small employer health benefits plan, mammogram examination benefits. 8. Every small employer health benefits plan that is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) or approved for issuance or renewal in this State, on or after the effective date of this act, shall provide benefits to any woman 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. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan. The provisions of this section shall apply to all health benefit plans in which the carrier has reserved the right to change the premium. L.2004,c.86,s.8. 17B:27A-19.14 High deductible health plan, small employer, deductible inapplicable, certain circumstances. 16. Notwithstanding the provisions of subsection k. of section 3 of P.L.1992, c.162 (C.17B:27A-19) regarding deductibles for a high deductible health plan, a health benefits plan offered pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.) on or after the effective date of P.L.2005, c.248 (C.17:48E-35.27 et al.), that qualifies as a high deductible health plan for which qualified medical expenses are paid using a health savings account established pursuant to section 223 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.223), shall not apply a deductible for any benefits 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 small employer health benefits plans in which the carrier has reserved the right to change the premium. L.2005,c.248,s.16. 17B:27A-19.15 Small employer health benefits plan, coverage for prescription female contraceptives. 8. A small employer health benefits plan required pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19) that provides benefits for expenses incurred in the purchase of outpatient prescription drugs shall provide coverage 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 a carrier shall grant, an exclusion under the health benefits plan 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 covered persons and covered persons. The provisions of this section shall not be construed as authorizing a carrier 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 a covered person. 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 health benefits plan. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium. L.2005,c.251,s.8. 17B:27A-19.16 Coverage for certain dependents until age 30 by small employer health benefits plan. 5. a. As used in this section, ~dependent~ means a covered person@s child by blood or by law who: (1) is less than 30 years of age; (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) 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.89-97 (42 U.S.C. s.1395 et seq.). b. (1) A small employer health benefits plan that provides coverage for a covered person@s dependent under which coverage of the dependent terminates at a specific age before the dependent@s 30th birthday, and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 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 section, 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 30th birthday. (2) Nothing herein shall be construed to require: (a) coverage for services provided to a dependent before the effective date of this section; or (b) that an employer pay all or part of the cost of coverage for a dependent as provided pursuant to this section. c. (1) A dependent covered by a covered person@s plan, which coverage under the plan terminates at a specific age 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 plan; (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 plan previously terminated; or (c) during a 30-day period in each year following the year coverage terminates at the specific age as provided in the plan, which period shall begin on the anniversary date on which the dependent@s coverage terminates at the specific age as provided in the plan, if the dependent meets the requirements for dependent status as set forth in subsection a. of this section during the 30-day period. (2) For 12 months after the effective date of this section, a dependent who qualifies for dependent status as set forth in subsection a. of this section, but whose coverage as a dependent under a covered person@s plan terminated under the terms of the plan prior to the effective date of this section, may make a written election to reinstate coverage under that plan as a dependent pursuant to this section. 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 plan. If coverage is modified under the plan for any similarly situated dependents for coverage prior to the termination of coverage at the specific age provided in the plan, 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 covered person@s plan may require payment of a premium by the covered person 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 plan prior to the termination of coverage at the specific age provided in the plan. (2) The applicable portion of the premium previously paid for the dependent@s coverage under the plan shall be determined pursuant to regulations promulgated by the Commissioner of Banking and Insurance, based upon the difference between the plan@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 dependent is disqualified for dependent status as set forth in subsection a. of this section; (2) the date on which coverage ceases under the plan by reason of a failure to make a timely payment of any premium required under the plan by the covered person 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 plan; or (3) the date upon which the employer under whose plan coverage is provided to a dependent ceases to provide coverage to the covered person. Nothing herein shall be construed to permit a carrier 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. g. Notice regarding coverage for a dependent as provided pursuant to this section shall be provided to a covered person: (1) in the certificate of coverage prepared for covered persons by the carrier on or about the date of commencement of coverage; and (2) by the covered person@s employer: (a) on or before the coverage of a covered person@s dependent terminates at the specific age as provided in the plan; (b) at the time coverage of the dependent is no longer provided pursuant to this section because the dependent is disqualified for dependent status as set forth in subsection a. of this section, except this employer notice shall not be required when a dependent no longer qualifies based upon paragraph (1) or (3) of subsection a. of this section; (c) before the 30 day period in each year following the year coverage terminates at the specific age as provided in the plan, permitting a dependent to make a written election for coverage pursuant to subsection c. of this section; and (d) immediately following the effective date of this section, with respect to information concerning a dependent@s opportunity, for 12 months after the effective date of this section, to make a written election to reinstate coverage under a plan pursuant to paragraph (2) of subsection c. of this section. h. This section shall apply to those plans in which the carrier has reserved the right to change the premium. L.2005,c.375,s.5.

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