N.J. Stat. § 26:2S-1 Short title
1. This act shall be known and may be cited as the "Health Care Quality Act." L.1997,c.192,s.1.
N.J. Stat. tit. 26, ch. 2S
N.J. Stat. tit. 26, ch. 2S
in effectN.J. Stat. § 26:2S-2 Definitions relative to health care quality.
2. As used in sections 2 through 19 of this act: "Behavioral health care services" means procedures or services rendered by a health care provider for the treatment of mental illness, emotional disorders, or drug or alcohol abuse. "Behavioral health care services" does not include: any quality assurance or utilization management activities or treatment plan reviews conducted by a carrier, or a private entity on behalf of the carrier, pertaining to these services, whether administrative or clinical in nature; or any other administrative functions, including, but not limited to, accounting and financial reporting, billing and collection, data processing, debt or debt service, legal services, promotion and marketing, or provider credentialing. "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State. "Commissioner" means the Commissioner of Banking and Insurance. "Contract holder" means an employer or organization that purchases a contract for services. "Covered person" means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan. "Covered service" means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services. "Department" means the Department of Banking and Insurance. "Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. Health benefits plan includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. For the purposes of this act, health benefits plan shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement coverage, 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. "Health care provider" means an individual or entity which, acting within the scope of its licensure or certification, provides a covered service defined by the health benefits plan. Health care provider includes, but is not limited to, a physician and other health care professionals licensed pursuant to Title 45 of the Revised Statutes, and a hospital and other health care facilities licensed pursuant to Title 26 of the Revised Statutes. "Independent utilization review organization" means an independent entity comprised of physicians and other health care professionals who are representative of the active practitioners in the area in which the organization will operate and which is under contract with the department to provide medical necessity or appropriateness of services appeal reviews pursuant to this act. "Managed behavioral health care organization" means an entity, other than a carrier, which contracts with a carrier to provide, undertake to arrange, or administer behavioral health care services to covered persons through health care providers employed by the managed behavioral health care organization or otherwise make behavioral health care services available to covered persons through contracts with health care providers. "Managed behavioral health care organization" does not include a person or entity that, for an administrative fee only, solely arranges a panel of health care providers for a carrier for the provision of behavioral health care services on a discounted fee-for-service basis. "Managed care plan" means a health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangements with participating providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating providers and procedures provided for in the plan. "Subscriber" means, in the case of a group contract, a person whose employment or other status, except family status, is the basis for eligibility for enrollment by the carrier or, in the case of an individual contract, the person in whose name the contract is issued. "Utilization management" means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the health benefits plan. The system may include: preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory care procedures, and retrospective review. L.1997, c.192, s.2; amended 2005, c.172, s.1; 2012, c.17, s.294.
N.J. Stat. § 26:2S-3 Form to be filed by carrier; minimum information required
3. a. A carrier which offers a health benefits plan to residents of this State on the effective date of this act, shall file a form, as prescribed by the commissioner, with the department within 90 days of the effective date of this act and file a copy of the form with the Department of Banking and Insurance. A carrier authorized to issue health benefits plans in this State after the effective date of this act shall file a form with the department at least 30 days prior to the date the carrier will begin to offer a health benefits plan to residents of this State. The carrier shall file a copy of the form with the Department of Banking and Insurance. A carrier shall notify the department within 10 business days of any change in information provided on the form. b. The commissioner shall establish a form for carriers which shall request, at a minimum: (1) the official address and telephone number of the place of business of the carrier; and (2) a description of the carrier's internal patient appeals process available to covered persons to contest a denial, reduction or termination of benefits, if any. c. A health maintenance organization which holds a certificate of authority pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall be exempt from the filing requirements of this section but shall comply with the provisions of this act. A health maintenance organization shall be required to comply with the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) and any rules and regulations adopted pursuant thereto, except that in the event that the provisions of this act conflict with the provisions of P.L.1973, c.337, the provisions of this act shall supersede the provisions of P.L.1973, c.337. d. A carrier which issues health benefits plans utilizing a selective contracting arrangement pursuant to section 22 of P.L.1993, c.162 (C.17B:27A-54) shall be required to comply with the provisions of section 22 of P.L.1993, c.162 and any rules and regulations adopted pursuant thereto, except that in the event that the provisions of this act conflict with the provisions of section 22 of P.L.1993, c.162, the provisions of this act shall supersede the provisions of section 22 of P.L.1993, c.162. L.1997,c.192,s.3.
N.J. Stat. § 26:2S-3.1 Short title.
1. This act shall be known and may be cited as the “Ensuring Fairness in Cost-Sharing Amounts Act of 2025.” L.2025, c.199, s.1.
N.J. Stat. § 26:2S-3.2 Definitions.
2. As used in section 3 of P.L.2025, c.199 (C.26:2S-3.3): “Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, or any other entity subject to the insurance laws and rules of insurance in this State or subject to the jurisdiction of the Department of Banking and Insurance, that contracts, or offers to contract, to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan in this State. “Cost-sharing amount” means any copayment, coinsurance, deductible, or other similar charges required of an enrollee for a health care service covered by a health benefits plan, including a prescription drug, and paid by or on behalf of the enrollee. “Enrollee” means any individual entitled to coverage of health care services from a carrier. “Health benefits plan” means a policy, contract, certification, or agreement offered or issued by a carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services. For the purposes of P.L.2025, c.199 (C.26:2S-3.1 et al.), “health benefits plans” shall not include the following plans, policies, or contracts: accident only; credit disability; long-term care; Medicare supplemental coverage; TRICARE supplement coverage; coverage for Medicare services pursuant to a contract with the United States government; the State Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.); coverage arising out of a worker’s compensation or similar law; the State Health Benefits Program; the School Employees’ Health Benefits Program; a self-insured health benefits plan governed by the provisions of the federal “Employee Retirement Income Security Act of 1974,” 29 U.S.C. s.1001 et seq.; coverage under a policy of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.); or hospital confinement indemnity coverage. “Health care service” means an item or service furnished to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury, or disability. “Third-party administrator” has the same meaning as defined in N.J.S.17B:27B-1. L.2025, c.199, s.2.
N.J. Stat. § 26:2S-3.3 Requirements for carriers and third-party administrators.
3. a. The annual limitation on cost-sharing amounts provided for in section 1302 of the Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18022), shall apply to all health care services covered under any health benefits plan offered or issued by a carrier in this State. Nothing in this subsection shall be construed to limit or supersede the authority of the Department of Banking and Insurance to impose additional cost-sharing limits consistent with State law and regulations, including minimum standards established pursuant to N.J.A.C.11:22-5.1 et seq. b. When calculating an enrollee’s contribution to any applicable cost-sharing amount requirement, a carrier or third-party administrator shall give credit for the amount, or any portion thereof, of any cost-sharing amount paid by the enrollee or on behalf of the enrollee by another party. If a health benefits plan qualifies as a high-deductible health plan for which 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), this subsection shall apply to a high-deductible health plan with respect to the deductible after the enrollee has satisfied the minimum deductible required under section 223, except for with respect to items or services that are preventive care pursuant to section 223(c)(2)(C) of the federal Internal Revenue Code (26 U.S.C. s.223), in which case the requirements of this subsection shall apply regardless of whether the minimum deductible under section 223 has been satisfied. c. A carrier or third-party administrator shall not directly or indirectly set, alter, implement, or condition the terms of health benefits plan coverage, including the benefit design, based in part or entirely on information about the availability or amount of financial or product assistance available for a prescription drug. d. By March 31 of each year, each carrier and third-party administrator authorized to conduct business in the State shall certify to the Commissioner of Banking and Insurance, in a form and manner as determined by the commissioner, that it has fully and completely complied with the requirements of this section throughout the prior calendar year. The certification shall be signed by the chief executive officer, chief financial officer, or designee, of the carrier or third-party administrator. e. The Commissioner of Banking and Insurance, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this section. L.2025, c.199, s.3.
N.J. Stat. § 26:2S-4 Disclosure of terms and conditions in writing to subscriber.
4. A carrier shall disclose in writing to a subscriber, in a manner consistent with the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.), the terms and conditions of its health benefits plan, and shall promptly provide the subscriber with written notification of any change in the terms and conditions prior to the effective date of the change. The carrier shall provide the required information at the time of enrollment and upon request thereafter. a. The information required to be disclosed pursuant to this section shall include a description of: (1) covered services and benefits to which the subscriber or other covered person is entitled; (2) restrictions or limitations on covered services and benefits, including, but not limited to, physical and occupational therapy services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, radiological examinations and behavioral health care services; (3) financial responsibility of the covered person, including copayments and deductibles; (4) prior authorization and any other review requirements with respect to accessing covered services; (5) where and in what manner covered services may be obtained; (6) changes in covered services or benefits, including any addition, reduction or elimination of specific services or benefits; (7) the covered person's right to appeal and the procedure for initiating an appeal of a utilization management decision made by or on behalf of the carrier with respect to the denial, reduction or termination of a health care benefit or the denial of payment for a health care service; (8) the procedure to initiate an appeal through the Independent Health Care Appeals Program established pursuant to this act; and (9) such other information as the commissioner shall require. b. The carrier shall file the information required pursuant to this section with the department. c. In the case of a carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization, the information required to be disclosed pursuant to this section shall include the following: (1) the specific behavioral health care services covered and the specific exclusions that apply to the subscriber or other covered person; (2) the covered person's responsibilities for obtaining behavioral health care services; (3) the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse health care providers for behavioral health care services; and (4) if the carrier offers a managed care plan that provides for both in-network and out-of-network benefits, the procedure that a covered person must utilize when attempting to obtain behavioral health care services from a health care provider who is not included in the network of providers used by the carrier or managed behavioral health care organization. L.1997,c.192,s.4; amended 2005, c.172, s.2.
N.J. Stat. § 26:2S-5 Additional disclosure requirements.
5. a. In addition to the disclosure requirements provided in section 4 of this act, a carrier which offers a managed care plan shall disclose to a subscriber, in writing, in a manner consistent with the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.), the following information at the time of enrollment and annually thereafter: (1) A current participating provider directory providing information on a covered person's access to primary care physicians and specialists, including the number of available participating physicians, by provider category or specialty and by county. The directory shall include the professional office address of a primary care physician and any hospital affiliation the primary care physician has. The directory shall also provide information about participating hospitals. In the case of a carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization, the directory shall include a list of participating providers of behavioral health care services with the address of each provider. The carrier shall promptly notify each covered person prior to the termination or withdrawal from the carrier's provider network of the covered person's primary care physician; (2) General information about the financial incentives between participating physicians under contract with the carrier and other participating health care providers and facilities to which the participating physicians refer their managed care patients; (3) The percentage of the carrier's managed care plan's network physicians who are board certified; (4) The carrier's managed care plan's standard for customary waiting times for appointments for urgent and routine care; (5) The availability through the department, upon request of a member of the general public, of independent consumer satisfaction survey results and an analysis of quality outcomes of health care services of managed care plans in the State; (6) Information about the Managed Health Care Consumer Assistance Program established pursuant to P.L.2001, c.14 (C.26:2S-19 et al.) as prescribed by regulation of the commissioner, including the toll-free telephone number available to contact the program; and (7) The carrier's preauthorization and review requirements of the health benefits plan regarding the determination of medical necessity that apply to a covered person who is admitted to an in-network health care facility, and the financial responsibility of the patient for the cost of services provided by an out-of-network admitting or attending health care practitioner. The carrier shall provide a prospective subscriber with information about the provider network, including hospital affiliations, and other information specified in this subsection, upon request. b. Upon request of a covered person, a carrier shall promptly inform the person: (1) whether a particular network physician is board certified; and (2) whether a particular network physician is currently accepting new patients. c. The carrier shall file the information required pursuant to this section with the department. L.1997,c.192,s.5; amended 2001, c.14, s.7; 2001, c.367, s.1; 2005, c.172, s.3.
N.J. Stat. § 26:2S-5.1 Health insurance carriers to provide organ, tissue donation information to subscribers.
1. a. A carrier shall provide to subscribers written informational materials about organ and tissue donation and registration at each contract renewal. The materials shall be developed or approved by a federally designated organ procurement organization, and shall inform subscribers as to how to make an anatomical gift, including information on the registration of a gift in the Donate Life New Jersey registry. b. For purposes of this section, "carrier," as defined in P.L.1997, c.192 (C.26:2S-1 et al.), shall also include the State Health Benefits Program and the School Employees' Health Benefits Program. L.2017, c.220, s.1.
N.J. Stat. § 26:2S-6 Designation of licensed physician as medical director for managed care
6. a. A carrier which offers a managed care plan or uses a utilization management system in any of its health benefits plans shall designate a licensed physician to serve as medical director. The medical director, or his designee, shall be designated to serve as the medical director for medical services provided to covered persons in the State and shall be licensed to practice medicine in New Jersey. The medical director shall be responsible for treatment policies, protocols, quality assurance activities and utilization management decisions of the carrier. The treatment policies, protocols, quality assurance program and utilization management decisions of the carrier shall be based on generally accepted standards of health care practice. The quality assurance and utilization management programs shall be in accordance with standards adopted by regulation of the department pursuant to this act. b. The medical director shall ensure that: (1) Any utilization management decision to deny, reduce or terminate a health care benefit or to deny payment for a health care service, because that service is not medically necessary, shall be made by a physician. In the case of a health care service prescribed or provided by a dentist, the decision shall be made by a dentist; (2) A utilization management decision shall not retrospectively deny coverage for health care services provided to a covered person when prior approval has been obtained from the carrier for those services, unless the approval was based upon fraudulent information submitted by the covered person or the participating provider; (3) In the case of a managed care plan, a procedure is implemented whereby participating physicians and dentists have an opportunity to review and comment on all medical and surgical and dental protocols, respectively, of the carrier; (4) The utilization management program is available on a 24-hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for nonurgent health care services; and (5) In the case of a managed care plan, a covered person is permitted to: choose or change a primary care physician from among participating providers in the provider network, and, when appropriate, choose a specialist from among participating network providers following an authorized referral, if required by the carrier, and subject to the ability of the specialist to accept new patients. L.1997,c.192,s.6.
N.J. Stat. § 26:2S-6.1 Managed care plan to pay full contractual rate to out-of-network provider, direct payments, certain circumstances.
2. a. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that: (1) a covered person is admitted by an out-of-network health care provider to an in-network health care facility for covered, medically necessary health care services; or (2) the covered person receives covered, medically necessary health care services from an out-of-network health care provider while the covered person is a patient at an in-network health care facility and was admitted to the health care facility by an in-network provider, the carrier shall reimburse the health care facility for the services provided by the facility at the carrier's full contracted rate without any penalty for the patient's selection of an out-of-network provider, in accordance with the in-network policies and in-network copayment, coinsurance or deductible requirements of the managed care plan. b. The provisions of subsection a. of this section shall apply only if the covered person complies with the preauthorization or review requirements of the health benefits plan regarding the determination of medical necessity to access in-network inpatient benefits, as set forth in writing pursuant to section 5 of P.L.1997, c.192 (C.26:2S-5). c. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that the covered person assigns, through an assignment of benefits, his right to receive reimbursement for medically necessary health care services to an out-of-network health care provider, the carrier shall remit payment for the reimbursement directly to the health care provider in the form of a check payable to the health care provider, or in the alternative, to the health care provider and the covered person as joint payees, with a signature line for each of the payees. Payment shall be made in accordance with the provisions of this section and P.L.1999, c.154 (C.17B:30-23 et al.). Any payment made only to the covered person rather than the health care provider under these circumstances shall be considered unpaid, and unless remitted to the health care provider within the time frames established by P.L.1999, c.154 (C.17B:30-23 et al.), shall be considered overdue and subject to an interest charge as provided in that act. L.2001, c.367, s.2; amended 2009, c.209.
N.J. Stat. § 26:2S-6.2 Waiver of health insurance copayments for certain active duty military and their families.
1. a. Notwithstanding any other law or contract provision to the contrary, if a covered person is a member of the military serving on active duty, or a family member of the covered person on active duty, who is also a covered person under the health benefits plan, a primary care physician or an advanced practice nurse may waive that covered person's copayment that would otherwise be collected as payment for treatment by the primary care physician or the advanced practice nurse for a covered service pursuant to a participating provider contract between the primary care physician or the advanced practice nurse and a carrier providing a health benefits plan. b. For the purposes of this section, "carrier" shall include, in addition to an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, the State Health Benefits Commission and the School Employees' Health Benefits Commission. L.2019, c.111, s.1.
N.J. Stat. § 26:2S-7 Review of application for participation
7. Each application for participation by a licensed health care professional that is submitted to a carrier which offers a managed care plan shall be reviewed by a committee of the carrier that includes appropriate representation of health care professionals with knowledge in the applicant's scope of professional practice. L.1997,c.192,s.7.
N.J. Stat. § 26:2S-7.1 Universal application for credentialing physicians for a carrier's provider network.
1. The Commissioner of Banking and Insurance, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association, and such other representatives of managed care plans as the commissioner deems appropriate, shall adopt by regulation, a universal physician application for participation form for use by carriers which offer managed care plans for the purpose of credentialing physicians who seek to participate in a carrier's provider network and for the purpose of credentialing physicians who are employed by hospitals or other health care facilities which seek to participate in a carrier's provider network. The commissioner, in consultation with the New Jersey Association of Health Plans, the Health Insurance Association of America, the Medical Society of New Jersey, the New Jersey Hospital Association and such other representatives of managed care plans as the commissioner deems appropriate, shall also adopt by regulation a form for renewal of credentialing, which shall be an abbreviated version of the universal application form. The renewal form shall be designed to enable a physician to indicate changes in the information provided in the application form. The commissioner shall revise the universal application and renewal forms, as necessary, to conform with industry-wide, national standards for credentialing. In developing the forms, the commissioner shall consult with the Commissioner of Human Services to ensure that the credentialing requirements for participation in the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), and the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.) are adequately reflected on the application and renewal forms. L.2001, c.88, s.1; amended 2012, c.17, s.295.
N.J. Stat. § 26:2S-7.2 Acceptance of application by carriers
2. Within 180 days of the adoption of the forms by regulation pursuant to this act, a carrier which offers a managed care plan shall accept the universal physician application for participation form and renewal form adopted pursuant to this act for the purpose of credentialing physicians who seek to participate in the carrier's provider network and for the purpose of credentialing physicians who are employed by hospitals or other health care facilities which seek to participate in the carrier's provider network. Nothing in this section shall be construed to prevent a carrier from requesting additional information from an applicant that is not provided for in the universal application or renewal form, as applicable, if the requested information does not duplicate any information included in the applicable form. L.2001,c.88,s.2.
N.J. Stat. § 26:2S-7.3 Rules, regulations.
3. The Commissioner of Banking and Insurance shall adopt regulations within 180 days of the date of enactment of this act, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act. L.2001, c.88, s.3; amended 2012, c.17, s.296.
N.J. Stat. § 26:2S-8 Establishment of policy governing removal of health care providers
8. A carrier which offers a managed care plan shall establish a policy governing removal of health care providers from the provider network which includes the following: a. The carrier shall inform a participating health care provider of the carrier's removal policy at the time the carrier contracts with the health care provider to participate in the provider network, and at each renewal thereof. b. If a licensed health care professional's participation will be terminated prior to the date of the termination of the contract, the carrier shall provide the health care professional with 90 days' written notice of the termination and notice of a right to a hearing. If requested by the health care professional, the carrier shall provide the reasons for the termination in writing, and shall hold a hearing within 30 days of the date of the request. The hearing shall be conducted by a panel appointed by the carrier, which panel shall be comprised of a minimum of three persons, at least one of whom is a clinical peer in the same discipline and the same or similar specialty as the health care professional being reviewed. The panel shall make a decision that: (1) the health care professional shall be terminated, or (2) the health care professional shall be reinstated or provisionally reinstated, subject to conditions set forth by the panel. The panel's determination shall be in writing and shall be made in a timely manner. Participation in this process shall not be deemed to be an abrogation of the health care professional's legal rights. The notice required and opportunity for a hearing pursuant to this subsection shall not apply in those cases when the contract expires and is not renewed, the termination is for breach of contract, in the opinion of the medical director, the health care professional represents an imminent danger to an individual patient or the public health, safety or welfare, or there is a determination of fraud. c. If the carrier finds that a health care professional represents an imminent danger to an individual patient or to the public health, safety or welfare, the medical director shall promptly notify the appropriate professional State licensing board. Notification to the State Board of Medical Examiners shall be subject to the provisions of section 5 of P.L.1989, c.300 (C.45:9-19.5). L.1997,c.192,s.8.
N.J. Stat. § 26:2S-9 Contract terms concerning appropriate medical care
9. The contract between a participating health care provider and a carrier which offers a managed care plan: a. Shall state that the health care provider shall not be penalized or the contract terminated by the carrier because the health care provider acts as an advocate for the patient in seeking appropriate, medically necessary health care services; b. Shall not provide financial incentives to the health care provider for withholding covered health care services that are medically necessary as determined in accordance with section 6 of this act, except that nothing in this subsection shall be construed to limit the use of capitated payment arrangements between a carrier and a health care provider; and c. Shall protect the ability of a health care provider to communicate openly with a patient about all appropriate diagnostic testing and treatment options. L.1997,c.192,s.9.
N.J. Stat. § 26:2S-9.1 Managed care plan, continuing treatment of certain patients by physician no longer employed by plan; required.
1. a. Notwithstanding the provisions of any law to the contrary, a carrier which offers a managed care plan shall provide in that plan that if a covered person is receiving post-operative follow-up care, oncological treatment, psychiatric treatment or obstetrical care by a physician who is employed by or under contract with a carrier at the time the treatment is initiated, the covered person may continue to be treated by that physician for the duration of the treatment in the event that the physician is no longer employed by or under contract with the carrier as follows: (1) for a period not to exceed six months in the case of post-operative follow-up care; (2) for a period not to exceed one year in the case of oncological treatment and psychiatric treatment; and (3) through the duration of a pregnancy and up to six weeks after delivery in the case of obstetrical care. The continuation of treatment by a particular physician as provided for in this subsection shall be at the option of the covered person. The carrier shall provide that health care benefits or services, as appropriate, shall be provided for the treatment of the conditions provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier. b. A carrier which offers a managed care plan shall also provide in that plan for continued coverage of other health care services by a physician who was employed by or under contract with the carrier at the time the treatment was initiated, but is no longer employed by or under contract with the carrier, for up to 120 calendar days in cases where it is medically necessary for the covered person to continue treatment with that physician. Health care benefits or services, as applicable, shall be provided by the health benefits plan for medically necessary treatment as provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier. c. During the period of time a covered person is continuing to receive treatment pursuant to subsection a. or b. of this section by a physician who is no longer employed by or under contract with the carrier, the carrier shall provide in its plan for reimbursement for any treatment or services provided or delivered to the covered person in an acute care hospital, regardless of whether the acute care hospital is under contract or agreement with the carrier. d. The carrier shall not be liable for any inappropriate treatment provided to the covered person by a physician who is no longer employed by or under contract with the carrier. e. The provisions of this section shall not apply to health care services provided by a physician who is the subject of disciplinary action by the State Board of Medical Examiners. L.1999,c.390,s.1.
N.J. Stat. § 26:2S-9.2 Written fee schedule information furnished to health care providers, proprietary information.
1. a. A carrier which offers a managed care plan that negotiates with a health care provider to become a participating provider, who is reimbursed per procedure under the plan, shall, upon request, furnish the health care provider with a written fee schedule, or in an electronic format if agreed upon by both parties, showing the fees for the 20 most common evaluation and management codes and the 20 most common office-based or hospital-based in-network services for the health care provider's specialty or sub-specialty, to be provided by the health care provider under the plan pursuant to the proposed or existing contract between the carrier and health care provider. If the carrier negotiates with the health care provider to become a participating provider under more than one managed care plan offered by the carrier, the carrier shall provide the applicable fee schedule for each plan. If the carrier negotiates a fee schedule with the health care provider that is specific to that health care provider, the carrier shall provide only the applicable fee schedule for that health care provider. If the rate that the health care provider will be paid is a percentage of another rate, it shall be sufficient for the carrier to provide that formula to the health care provider. The carrier shall furnish the fee schedule pursuant to this subsection within 15 days of the request of the provider. The fee schedule provided to the health care provider by the carrier is proprietary and shall be confidential. Unauthorized distribution of the fee schedule may result in the health care provider's termination from the network in accordance with the provisions of N.J.A.C. 8:38-1.1 et seq. b. The carrier shall reimburse the health care provider in accordance with the fee schedule provided to the health care provider pursuant to the contract. The carrier may revise the fee schedule upon providing the health care provider with written notice of the change and, upon request, a copy of the revised fee schedule. c. Nothing in this section shall be construed to limit the ability of a carrier to make payments under a managed care plan based on its claims payment policies. L.2005,c.286,s.1.
N.J. Stat. § 26:2S-9.3 Violations, penalty.
2. A carrier which violates any provision of this act shall be liable to a penalty of not more than $1,000 for each violation. Each failure to timely respond to a health care provider's request for a fee schedule shall be considered a separate violation. The penalty shall be collected by the Commissioner of Banking and Insurance in the name of the State in a summary proceeding in accordance with the "Penalty Enforcement Law of 1999," P.L.1999, c.274 (C.2A:58-10 et seq.). L.2005,c.286,s.2.
N.J. Stat. § 26:2S-10 Offer of point-of-service plan, terms
10. a. A carrier which offers a managed care plan shall offer a point-of-service plan to every contract holder which would allow a covered person to receive covered services from out-of-network health care providers without having to obtain a referral or prior authorization from the carrier. The point-of-service plan may require that a subscriber pay a higher deductible or copayment and higher premium for the plan, pursuant to limits established by the department, in consultation with the Department of Banking and Insurance, by regulation. b. A carrier shall provide each subscriber in a plan whose contract holder elects the point-of-service plan, with the opportunity, at the time of enrollment and during the annual open enrollment period, to enroll in the point-of-service plan option. The carrier shall provide written notice of the point-of-service plan to each subscriber in a plan whose contract holder elects the point-of-service plan and shall include in that notice a detailed explanation of the financial costs to be incurred by a subscriber who selects that plan. c. The requirements of this section shall not apply to a carrier contract which offers a managed care plan that provides health care services to Medicaid recipients pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or a federally qualified, nonprofit health maintenance organization. d. A carrier which offers a managed care plan utilizing a selective contracting arrangement approved in accordance with N.J.A.C.11:4-37.1 et seq. that provides benefits for out-of-network providers shall be deemed to be in compliance with this section. e. A health maintenance organization affiliated with an insurance company authorized to issue health benefits plans in this State that offers point-of-service benefits exclusively through a point-of-service plan provided by the affiliated insurance company using a selective contracting arrangement approved in accordance with N.J.A.C.11:4-37.1 et seq., shall be deemed to be in compliance with this section if the point-of-service plan is offered pursuant to the requirements of subsections a. and b. of this section. L.1997,c.192,s.10.
N.J. Stat. § 26:2S-10.1 Home treatment for bleeding episodes associated with hemophilia, required coverage.
1. A carrier which offers a managed care plan that provides benefits or health care services, as applicable, for the home treatment of bleeding episodes associated with hemophilia, including the purchase of blood products and blood infusion equipment, shall comply with the provisions of this section. a. For the purpose of providing home treatment services for bleeding episodes associated with hemophilia, the carrier shall be required to contract with, and exclusively use, providers that comply with standards adopted by regulation of the Department of Banking and Insurance in consultation with the Hemophilia Association of New Jersey. At a minimum, the standards shall require that each provider: (1) provide services pursuant to a prescription from the covered person's attending physician and not make any substitutions of blood products without prior approval of the attending physician; (2) provide all brands of clotting factor products in low, medium and high-assay range levels to execute treatment regimens as prescribed by a covered person's attending physician, and all needed ancillary supplies for the treatment or prevention of bleeding episodes, including, but not limited to, needles, syringes, and cold compression packs; (3) have the ability to deliver prescribed blood products, medications, and nursing services within three hours after receipt of a prescription for an emergent situation, and maintain 24-hour on-call service to accommodate this requirement; (4) demonstrate experience with and knowledge of bleeding disorders and the management thereof; (5) demonstrate the ability for appropriate and necessary record keeping and documentation, including the ability to expedite product recall or notification systems and the ability to assist covered persons in obtaining third party reimbursement; (6) provide for proper removal and disposal of hazardous waste pursuant to State and federal law; (7) provide covered persons with a written copy of the agency's policy regarding discontinuation of services related to loss of health benefits plan coverage or inability to pay; and (8) provide covered persons, upon request, with information about the expected costs for medications and services provided by the agency that are not otherwise covered by the covered person's health benefits plan. b. The Department of Banking and Insurance shall compile a list of providers who meet the minimum standards established pursuant to this section and shall make the list available to carriers and covered persons, upon request. c. As used in this section: "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. L.2000, c.121, s.1; amended 2012, c.17, s.297.
N.J. Stat. § 26:2S-10.2 Clinical laboratory services at outpatient regional hemophilia care center, required coverage
2. A carrier which offers a managed care plan shall provide payment for services to the clinical laboratory at a hospital with a State-designated outpatient regional hemophilia care center regardless of whether the hospital's clinical laboratory is a participating provider in the managed care plan, if the covered person's attending physician determines that use of the hospital's clinical laboratory is necessary because: a. the results of laboratory tests are medically necessary immediately or sooner than the normal return time for the carrier's participating clinical laboratory; or b. accurate test results need to be determined by closely supervised procedures in venipuncture and laboratory techniques in controlled environments that cannot be achieved by the carrier's participating clinical laboratory. The carrier shall pay the hospital's clinical laboratory for the laboratory services at the same rate it would pay a participating clinical laboratory for comparable services. The carrier shall retain the right to review all services provided pursuant to this section for medical necessity. L.2000,c.121,s.2.
N.J. Stat. § 26:2S-10.3 Regulations by department.
11. The Department of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt regulations to carry out the provisions of sections 1 and 2 of this act. L.2000, c.121, s.11; amended 2012, c.17, s.298.
N.J. Stat. § 26:2S-10.4 Optometrist not required to participate in certain plans.
1. a. A carrier shall not require an optometrist to participate in a vision care plan as a condition for entering into a contract with that carrier for the provision of medically necessary physician services within the scope of practice of an optometrist. b. Nothing in this section shall be construed to prevent a carrier from entering into a contract with a vision care plan. L.2017, c.264, s.1.
N.J. Stat. § 26:2S-10.5 Contract between carrier and vision care provider, fees permissible.
2. a. No contract between a carrier or a vision care plan and a vision care provider may seek to or require that a vision care provider provide services or materials at a fee limited or set by the carrier or vision care plan unless the services or materials are reimbursed as covered services or covered materials under the contract. b. A vision care provider shall not charge more for services and materials that are noncovered services or noncovered materials to an enrollee of a vision care plan or carrier than the provider's usual and customary rate for those services and materials. L.2017, c.264, s.2.
N.J. Stat. § 26:2S-10.6 Vision care provider, choice of sources, providers.
3. No contract between a carrier or vision care plan and a vision care provider shall restrict or limit, either directly or indirectly, the vision care provider's choice of sources and suppliers of services or materials or use of optical labs provided by the vision care provider to an enrollee. L.2017, c.264, s.3.
N.J. Stat. § 26:2S-10.7 Definitions relative to optometrists, vision care plans.
4. As used in this act: "Contractual discount" means a reduction from a vision care provider's usual and customary rate for covered services and materials required under a participating provider agreement. "Covered materials" means materials for which reimbursement from the carrier or vision care plan is provided to a vision care provider by a covered person's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance. "Covered services" means services for which reimbursement from the carrier or vision care plan is provided to a vision care provider by an enrollee's plan contract, or for which a reimbursement would be available but for the application of the enrollee's contractual limitations of deductibles, copayments, or coinsurance. "Materials" means ophthalmic devices including but not limited to lenses, devices containing lenses, ophthalmic frames and other lens mounting apparatus, prisms, lens treatments and coatings contact lenses, and prosthetic devices to correct, relieve, or treat defects or abnormal conditions of the human eye or its adnexa. "Services" means the professional work performed by a vision care provider. "Vision care plan" means an entity that creates, promotes, sells, provides, advertises or administers, an integrated or stand-alone vision benefit plan, or a vision care insurance policy or contract which provides vision or medically necessary benefits to an enrollee pertaining to the provision of covered services or covered materials. "Vision care provider" means a licensed doctor of optometry practicing under the authority of R.S.45:12-1 et seq. or a licensed medical or osteopathic doctor practicing under the authority of R.S.45:9-1 et seq. that has also completed a residency in ophthalmology. L.2017, c.264, s.4.
N.J. Stat. § 26:2S-10.8 Definitions relative to insurance coverage for mental health conditions and substance use disorders.
11. a. For the purposes of this section: "Benefit limits" includes both quantitative treatment limitations and non-quantitative treatment limitations. "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State or any entity contracted to administer health benefits in connection with the State Health Benefits Program or School Employees' Health Benefits Program. "Classification of benefits" means the classifications of benefits found at 45 C.F.R. 146.136(c)(2)(ii)(A) and 45 C.F.R. s.146.136(c)(3)(iii). "Department" means the Department of Banking and Insurance. "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. "Non-quantitative treatment limitations" or "NQTL" means processes, strategies, or evidentiary standards, or other factors that are not expressed numerically, but otherwise limit the scope or duration of benefits for treatment. NQTLs shall include, but shall not be limited to: (1) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (2) Formulary design for prescription drugs; (3) For plans with multiple network tiers, such as preferred providers and participating providers, network tier design; (4) Standards for provider admission to participate in a network, including reimbursement rates; (5) Plan methods for determining usual, customary, and reasonable charges; (6) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, also known as fail-first policies or step therapy protocols; (7) Exclusions based on failure to complete a course of treatment; (8) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage; (9) In and out-of-network geographic limitations; (10) Limitations on inpatient services for situations where the participant is a threat to self or others; (11) Exclusions for court-ordered and involuntary holds; (12) Experimental treatment limitations; (13) Service coding; (14) Exclusions for services provided by a licensed professional who provides mental health condition or substance use disorder services; (15) Network adequacy; and (16) Provider reimbursement rates. "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. A carrier shall approve a request for an in-plan exception if the carrier's network does not have any providers who are qualified, accessible and available to perform the specific medically necessary service. A carrier shall communicate the availability of in-plan exceptions: (1) on its website where lists of network providers are displayed; and (2) to beneficiaries when they call the carrier to inquire about network providers. c. A carrier that provides hospital or medical expense benefits through individual or group contracts shall submit an annual report to the department on or before March 1. The annual report shall contain, to the extent that the commissioner determines practicable, the following information: (1) A description of the process used to develop or select the medical necessity criteria for mental health benefits, the process used to develop or select the medical necessity criteria for substance use disorder benefits, and the process used to develop or select the medical necessity criteria for medical and surgical benefits; (2) Identification of all NQTLs that are applied to mental health benefits, all NQTLs that are applied to substance use disorder benefits, and all NQTLs that are applied to medical and surgical benefits, including, but not limited to, those listed in subsection a. of this section; (3) The results of an analysis that demonstrates that for the medical necessity criteria described in paragraph (1) of this subsection and for selected NQTLs identified in paragraph (2) of this subsection, as written and in operation, the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and selected NQTLs to mental health condition and substance use disorder benefits are comparable to, and are no more stringently applied than the processes, strategies, evidentiary standards, or other factors used to apply the medical necessity criteria and selected NQTLs, as written and in operation, to medical and surgical benefits. A determination of which selected NQTLs require analysis will be determined by the department; at a minimum, the results of the analysis shall entail the following, provided that some NQTLs may not necessitate all of the steps described below: (a) identify the factors used to determine that an NQTL will apply to a benefit, including factors that were considered but rejected; (b) identify and define the specific evidentiary standards, if applicable, used to define the factors and any other evidentiary standards relied upon in designing each NQTL; (c) provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to design each NQTL, as written, for mental health and substance use disorder benefits are comparable to and applied no more stringently than the processes and strategies used to design each NQTL as written for medical and surgical benefits; (d) provide the comparative analyses, including the results of the analyses, performed to determine that the processes and strategies used to apply each NQTL, in operation, for mental health and substance use disorder benefits are comparable to and applied no more stringently than the processes or strategies used to apply each NQTL in operation for medical and surgical benefits; and (e) disclose the specific findings and conclusions reached by the carrier that the results of the analyses above indicate that the carrier is in compliance with this section and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. s.18031(j), and its implementing and related regulations, which includes 45 C.F.R. s.146.136, 45 C.F.R. s.147.160, and 45 C.F.R. s.156.115(a)(3); and (4) Any other information necessary to clarify data provided in accordance with this section requested by the Commissioner of Banking and Insurance including information that may be proprietary or have commercial value, provided that no proprietary information shall be made publicly available by the department. d. The department shall implement and enforce applicable provisions of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C. 18031(j), any amendments to, and federal guidance or regulations issued under that act, including 45 C.F.R. Parts 146 and 147, 45 C.F.R. s.156.115(a)(3), P.L.1999, c.106 (C.17:48-6v et al.), and section 2 of P.L.1999, c.441 (C.52:14-17.29e), which includes: (1) Ensuring compliance by individual and group contracts, policies, plans, or enrollee agreements delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), P.L.1940, c.74 (C.17:48A-1 et seq.), P.L.1985, c.236 (C.17:48E-1 et seq.), chapter 26 of Title 17B of the New Jersey Statutes (N.J.S.17B:26-1 et seq.), chapter 27 of Title 17B of the New Jersey Statutes (N.J.S.17B:27-26 et seq.), P.L.1992, c.161 (C.17B:27A-2 et seq.), P.L.1992, c.162 (C.17B:27A-17 et seq.), P.L.1973, c.337 (C.26:2J-1 et seq.), and P.L.1961, c.49 (C.52:14-17.25 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance. (2) Detecting violations of the law by individual and group contracts, policies, plans, or enrollee agreements delivered, issued, executed, or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), P.L.1940, c.74 (C.17:48A-1 et seq.), P.L.1985, c.236 (C.17:48E-1 et seq.), chapter 26 of Title 17B of the New Jersey Statutes (N.J.S.17B:26-1 et seq.), chapter 27 of Title 17B of the New Jersey Statutes (N.J.S.17B:27-26 et seq.), P.L.1992, c.161 (C.17B:27A-2 et seq.), P.L.1992, c.162 (C.17B:27A-17 et seq.), P.L.1973, c.337 (C.26:2J-1 et seq.), and P.L.1961, c.49 (C.52:14-17.25 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance. (3) Accepting, evaluating, and responding to complaints regarding violations. (4) Maintaining and regularly reviewing for possible parity violations a publicly available consumer complaint log regarding mental health condition and substance use disorder coverage, provided that the names of specific carriers will be redacted and not disclosed on the complaint log. (5) The commissioner shall adopt rules as may be necessary to effectuate any provisions of this section and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 that relate to the business of insurance. e. Not later than May 1 of each year, the department shall issue a report to the Legislature pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1). The report shall: (1) Describe the methodology the department is using to check for compliance with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C s.18031(j), and any federal regulations or guidance relating to the compliance and oversight of that act. (2) Describe the methodology the department is using to check for compliance with P.L.1999, c.106 (C.17:48-6v et al.) and section 2 of P.L.1999, c.441 (C.52:14-17.29e). (3) Identify market conduct examinations conducted or completed during the preceding 12-month period regarding compliance with parity in mental health and substance use disorder benefits under state and federal laws and summarize the results of such market conduct examinations. This shall include: (a) The number of market conduct examinations initiated and completed; (b) The benefit classifications examined by each market conduct examination; (c) The subject matters of each market conduct examination, including quantitative and non-quantitative treatment limitations; (d) A summary of the basis for the final decision rendered in each market conduct examination; and (e) Individually identifiable information shall be excluded from the reports consistent with state and Federal privacy protections. (4) Detail any educational or corrective actions the department has taken to ensure compliance with Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 U.S.C s.18031(j), P.L.1999, c.106 (C.17:48-6v et al.) and section 2 of P.L.1999, c.441 (C.52:14-17.29e). (5) Detail the department's educational approaches relating to informing the public about mental health condition and substance use disorder parity protections under State and federal law. (6) Be written in non-technical, readily understandable language and shall be made available to the public by, among such other means as the department finds appropriate, posting the report on the department's website. f. The department shall post on its Internet website a report disclosing the department's conclusions as to whether the analyses collected from the carriers as specified in paragraph (3) of subsection c. of this section demonstrate compliance with the Mental Health Parity and Addiction Equity Act of 2008 and its implementing regulations, specifically including whether or not there is compliance with 45 C.F.R. 146.136(c)(4). The name and identity of carriers shall be confidential, shall not be made public by the department, and shall not be subject to public inspection. L.2019, c.58, s.11.
N.J. Stat. § 26:2S-10.9 Regulations for benefits carrier relative to prescription drug benefits.
3. a. A carrier that provides benefits for prescription drugs shall not require a covered person to make a payment at the point of sale for any amount for a deductible, coinsurance payment, or a copayment for a prescription drug benefit in an amount that exceeds the amount the covered person would pay for the prescription drug if the covered person purchased the prescription drug without using a health benefits plan. b. A carrier shall not prohibit a network pharmacy from disclosing, and shall not apply a penalty or any other type of disincentive to a network pharmacy that discloses, to a covered person lower cost prescription drug options, including those that are available to the covered person if the covered person purchases the prescription drug without using health insurance coverage. c. Any provision of a contract that conflicts with the provisions of subsection b. of this section shall be void and unenforceable. d. A violation of this section shall be an unlawful practice and a violation of P.L.1960, c.39 (C.56:8-1 et seq.), and shall also be subject to any enforcement action that the Commissioner of Banking and Insurance is authorized to take pursuant to section 5 of P.L.2015, c.179 (C.17B:27F-5) . L.2019, c.257, s.3.
N.J. Stat. § 26:2S-11 Independent Health Care Appeals Program.
11. There is established the Independent Health Care Appeals Program in the department. The purpose of the appeals program is to provide an independent medical necessity or appropriateness of services review of final decisions by carriers to deny, reduce, or terminate benefits in the event the final decision is contested by the covered person or any health care provider acting on behalf of the covered person, but only with the covered person's consent. The appeal review shall not include any decisions regarding benefits not covered by the covered person's health benefits plan. a. A covered person or health care provider may apply to the Independent Health Care Appeals Program for a review of a decision to deny, reduce, or terminate a benefit if the person or health care provider has already completed the carrier's appeals process, if any, and the person or health care provider contests the final decision by the carrier. The person or health care provider shall apply to the department within 60 days of the date the final decision was issued by the carrier in a manner determined by the commissioner. b. As part of the application, the covered person or health care provider shall provide the department with: (1) The name and business address of the carrier; (2) A brief description of the covered person's medical condition for which benefits were denied, reduced, or terminated; (3) A copy of any information provided by the carrier regarding its decision to deny, reduce, or terminate the benefit; and (4) A written consent to obtain any necessary medical records from the carrier and, in the case of a carrier which offers a managed care plan, any other out-of-network physician the person may have consulted on the matter. c. (Deleted by amendment, P.L.2025, c.75) d. Prior to receiving hospital services, a covered person or a person designated by the covered person may sign a consent form authorizing a health care provider acting on the covered person's behalf to appeal a determination by the carrier to deny, reduce, or terminate benefits. The consent is valid for all stages of the carrier's informal and formal appeals process and the Independent Health Care Appeals Program established pursuant to this section. A covered person shall retain the right to revoke his consent at any time. e. A health care provider shall provide notice to the covered person whenever the health care provider initiates an appeal of a carrier's determination to deny, reduce, or terminate a benefit or deny payment for a health care service based on a medical necessity determination made by the carrier. The health care provider shall provide additional notice to the covered person each time the health care provider continues the appeal to the next stage of an appeals process, including any appeal to an independent utilization review organization pursuant to this section. L.1997,c.192,s.11; amended 2005, c.352, s.8; 2025, c.75.
N.J. Stat. § 26:2S-12 Contract to conduct appeal reviews; procedures.
12. a. The commissioner shall contract with one or more independent utilization review organizations in the State that meet the requirements of this act to conduct the appeal reviews. The independent utilization review organization shall be independent of any carrier. The commissioner may establish additional requirements, including conflict of interest standards, consistent with the purposes of this act that an organization shall meet in order to qualify for participation in the Independent Health Care Appeals Program. b. The commissioner shall establish procedures for transmitting the completed application for an appeal review to the independent utilization review organization. c. The independent utilization review organization shall promptly review the pertinent medical records of the covered person to determine the appropriate, medically necessary health care services the person should receive, based on applicable, generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards or associations and any applicable clinical protocols or practice guidelines developed by the carrier. The organization shall complete its review and make its determination within 90 days of receipt of a completed application for an appeal review or within less time, as prescribed by the commissioner. Upon completion of the review, the organization shall state its findings in writing and make a determination of whether the carrier's denial, reduction or termination of benefits deprived the covered person of medically necessary services covered by the person's health benefits plan. If the organization determines that the denial, reduction or termination of benefits deprived the person of medically necessary covered services, it shall convey to the covered person or the health care provider acting on behalf of the covered person and carrier its decision regarding the appropriate, medically necessary health care services that the person should receive, which shall be binding on the carrier. If all or part of the organization's decision is in favor of the covered person, the carrier shall promptly provide coverage for the health care services found by the organization to be medically necessary covered services. If the covered person is not in agreement with the organization's decision, the person may seek the desired health care services outside of his health benefits plan, at his own expense. d. If the commissioner determines that a carrier has failed to comply with the decision of an independent utilization review organization or is otherwise in violation of patient rights and other applicable regulations, the commissioner may impose such penalties and sanctions on the carrier, as provided by regulation, as the commissioner deems appropriate. e. The commissioner shall require the independent utilization review organization to establish procedures to provide for an expedited review of a carrier's denial, reduction or termination of a benefit decision when a delay in receipt of the service could seriously jeopardize the health or well-being of the covered person. f. The covered person's medical records provided to the Independent Health Care Appeals Program and the independent utilization review organization and the findings and recommendations of the organization made pursuant to this act are confidential and shall be used only by the department, the organization and the affected carrier for the purposes of this act. The medical records and findings and recommendations shall not otherwise be divulged or made public so as to disclose the identity of any person to whom they relate, and shall not be included under materials available to public inspection pursuant to P.L.1963, c.73 (C.47:1A-1 et seq.). g. The commissioner shall establish a reasonable, per case reimbursement schedule for the independent utilization review organization. h. The cost of the appeal review shall be borne by the carrier pursuant to a schedule of fees established by the commissioner. L.1997,c.192,s.12; amended 2001, c.1; 2005, c.352, s.9.
N.J. Stat. § 26:2S-13 Immunity from civil liability for participants in Independent Health Care Appeals Program
13. a. An employee of the department who participates in the Independent Health Care Appeals Program shall not be liable in any action for damages to any person for any action taken within the scope of his function in the Independent Health Care Appeals Program. The Attorney General shall defend the person in any civil suit and the State shall provide indemnification for any damages awarded. b. The carrier that is the subject of a review shall not be liable in any action for damages to any person for any action taken to implement a recommendation of the independent utilization review organization pursuant to this act. L.1997,c.192,s.13.
N.J. Stat. § 26:2S-14 Report to Legislature, Governor
14. The commissioner shall report every six months to the Senate and General Assembly standing reference committees on health and insurance and to the Governor on the status of the Independent Health Care Appeals Program. The report shall include a summary of the number of reviews conducted and medical specialties affected, a summary of the findings and recommendations made by the independent utilization review organization, any actions taken by the commissioner against a carrier pursuant to subsection d. of section 12 of this act and any other information and recommendations deemed appropriate by the commissioner. L.1997,c.192,s.14.
N.J. Stat. § 26:2S-14.1 General hospital to provide information concerning the Independent Health Care Appeals Program.
1. A general hospital licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.) shall be required, as prescribed by regulation of the Commissioner of Health, to: (1) post, in a conspicuous place in each of its waiting rooms for members of the general public, a notice, as prescribed pursuant to section 3 of P.L.2011, c.190 (C.26:2S-14.2), which provides information about the operation of, and how to apply for, the Independent Health Care Appeals Program established pursuant to section 11 of P.L.1997, c.192 (C.26:2S-11); and (2) ensure that appropriate hospital staff, including direct patient care providers, staff that are concerned with billing for hospital services or provide financial counseling to patients, and staff otherwise engaged in providing patient advocacy or patient relations services, are made aware of the program and are able to provide information to patients and their family members, or other persons on the patient's behalf, about how to contact the program. L.2011, c.190, s.1; amended 2012, c.17, s.299.
N.J. Stat. § 26:2S-14.2 Size, content, format of notice.
3. The Commissioner of Banking and Insurance, in consultation with the Commissioner of Health and the State Board of Medical Examiners, shall prescribe the size, content, and format of the notice about the Independent Health Care Appeals Program to be posted in general hospitals pursuant to section 1 of P.L.2011, c.190 (C.26:2S-14.1) and in physicians' medical offices pursuant to section 2 of P.L.2011, c.190 (C.45:9-22.26), and shall make the notice available to general hospitals and physicians, and to members of the general public, by posting it on the Internet website of the Department of Banking and Insurance. L.2011, c.190, s.3; amended 2012, c.17, s.300.
N.J. Stat. § 26:2S-14.3 Rules, regulations.
4. The Commissioner of Health and the State Board of Medical Examiners, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and in consultation with each other and the Commissioner of Banking and Insurance, shall adopt rules and regulations to effectuate the purposes of this act. L.2011, c.190, s.4; amended 2012, c.17, s.301.
N.J. Stat. § 26:2S-15 Compliance with department reporting requirements
15. a. A carrier which offers a managed care plan shall comply with department reporting requirements with respect to quality outcomes measures of health care services and independent consumer satisfaction surveys. b. The department shall make available to members of the general public, upon request, the results of the independent consumer satisfaction survey and the analysis of quality outcomes measures of health care services provided by managed care plans in the State, prepared by the department. L.1997,c.192,s.15.
N.J. Stat. § 26:2S-15.1 Annual report to carrier by managed behavioral health care organization.
4. a. A carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization shall require the managed behavioral health care organization to provide the carrier and the commissioner with an annual report, no later than March 15th of each year and covering the preceding calendar year, which includes the following information: (1) the payments made by the managed behavioral health care organization to health care providers for the provision of behavioral health care services to covered persons during the preceding calendar year, which shall be separately identified in the report from the other information that is required to be included pursuant to this subsection; (2) the total expenses incurred by the managed behavioral health care organization for quality assurance and utilization management activities and treatment plan reviews, whether administrative or clinical in nature, during the preceding calendar year, which shall be separately identified in the report; (3) the total expenses incurred by the managed behavioral health care organization for other administrative functions, including, but not limited to, accounting and financial reporting, billing and collection, data processing, debt or debt service, legal services, promotion and marketing, or provider credentialing, during the preceding calendar year, which shall each be separately identified in the report; and (4) the amount of any premiums or other fees received by the managed behavioral health care organization during the preceding calendar year. b. A carrier shall make available to a subscriber or other covered person, upon request, a copy of the report that is required pursuant to subsection a. of this section. The carrier may charge a fee, in an amount to be established by the commissioner, for furnishing a copy of the report or form to a subscriber or other covered person, which shall reasonably reflect the cost of preparation and the actual cost of postage and handling. L.2005,c.172,s.4.
N.J. Stat. § 26:2S-16 Violations, penalties
16. a. A carrier that violates any provision of this act shall be liable to a civil penalty of not less than $250 and not greater than $10,000 for each day that the carrier is in violation of the act if reasonable notice in writing is given of the intent to levy the penalty and, at the discretion of the commissioner, the carrier has 30 days, or such additional time as the commissioner shall determine to be reasonable, to remedy the condition which gave rise to the violation, and fails to do so within the time allowed. The penalty shall be collected by the commissioner in the name of the State in a summary proceeding in accordance with "the penalty enforcement law," N.J.S.2A:58-1 et seq. b. (1) The commissioner or the Commissioner of Banking and Insurance may issue an order directing a carrier or a representative of a carrier to cease and desist from engaging in any act or practice in violation of the provisions of this act. (2) Within 20 days after service of the order of cease and desist, the respondent may request a hearing on the question of whether acts or practices in violation of this act have occurred. The hearing shall be conducted pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and judicial review shall be available as provided therein. c. In the case of any violation of the provisions of this act, if the commissioner elects not to issue a cease and desist order, or in the event of noncompliance with a cease and desist order issued pursuant to subsection b. of this section, the commissioner may institute a proceeding to obtain injunctive relief in accordance with the applicable Court Rules. L.1997,c.192,s.16.
N.J. Stat. § 26:2S-17 Recommendations for legislative action
17. The commissioner and the Commissioner of Banking and Insurance shall develop recommendations for legislative action to address the issue of regulating health care or managed care entities that seek to contract directly with employers or other purchasers on a risk-assuming basis. The recommendations shall identify the type of health care or managed care entities and the scope of activities of these entities that should be subject to regulation by the State. In preparing the recommendations, the commissioners shall consider the current State statutory and regulatory requirements for health maintenance organizations and insurance companies issuing health benefits plans in the State, as well as federal legislation and laws and court rulings to determine how these health care and managed care entities that assume risk should be regulated. The commissioners shall report their recommendations to the Senate and General Assembly standing reference committees on health and insurance and to the Governor within one year of the effective date of this act. L.1997,c.192,s.17.
N.J. Stat. § 26:2S-18 Enforcement; rules, regulations
19. The commissioner shall enforce the provisions of this act. Within six months of the effective date of this act, in consultation with the Commissioner of Banking and Insurance, the commissioner shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act. The regulations shall establish consumer protection and quality standards governing carriers which offer a managed care plan or use a utilization management system that are consistent with the standards governing health maintenance organizations in the State. The regulations shall include standards for: a quality management program; provider participation in a network; adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network and access to medical specialists, when appropriate; utilization management as required in this act; a covered person complaint system; a patient appeals system as required in this act; the establishment of consumer rights of covered persons; carrier disclosure as required in this act; and outcomes and data reporting requirements as required in this act. L.1997,c.192,s.19.
N.J. Stat. § 26:2S-18.1 Publication of annual financial statements.
5. The Department of Banking and Insurance shall, for each carrier in the State, publish on the department's website the annual financial statement, in the format adopted by the National Association of Insurance Commissioners (NAIC) and in use at the time the statement is due, within 30 days of the receipt of that statement. L.2017, c.100, s.5.
N.J. Stat. § 26:2S-19 Findings, declarations relative to Managed Health Care Consumer Assistance Program
1. The Legislature finds and declares that: a. Managed health care, regardless of the form it takes, is now a major vehicle for the delivery of health care in this nation; and the rapid transition to managed health care has left consumers confused and concerned about how it affects them and how to navigate the managed health care system; b. Despite the clear promises of reduced costs, quality service and comprehensive care made by managed care plans, many consumers are uncertain about how to obtain appropriate care and inhibited in their efforts to do so. They often lack necessary information about the benefits and referral requirements of specific plans and have no access to resources which might assist them to obtain quality care on a timely basis; c. Consumers need help understanding their rights and responsibilities and how to access care and assert their rights in a complex managed care environment; and d. It is, therefore, in the public interest to establish a program to provide consumers with the information and assistance they need to access the high-quality, cost-effective health care available from managed care plans and to promote the rights and interests of managed care consumers. L.2001,c.14,s.1.
N.J. Stat. § 26:2S-20 Definitions relative to Managed Health Care Consumer Assistance Program.
2. As used in this act: "Carrier" means a carrier as defined in section 2 of P.L.1997, c.192 (C.26:2S-2). "Commissioner" means the Commissioner of Banking and Insurance. "Department" means the Department of Banking and Insurance. "Managed care plan" means a managed care plan as defined in section 2 of P.L.1997, c.192 (C.26:2S-2). "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.). "Medicare" means the federal Medicare program established pursuant to the federal Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.). "NJ FamilyCare" means the FamilyCare Health Coverage Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.). "Program" means the Managed Health Care Consumer Assistance Program established pursuant to this act. L.2001, c.14, s.2; amended 2012, c.17, s.302.
N.J. Stat. § 26:2S-21 Managed Health Care Consumer Assistance Program.
3. a. There is established the Managed Health Care Consumer Assistance Program in the Department of Banking and Insurance. The commissioner shall make agreements to operate the program as necessary, in consultation with the Commissioner of Human Services, to assure that citizens have reasonable access to services in all regions of the State. b. The program shall: (1) create and provide educational materials and training to consumers regarding their rights and responsibilities as enrollees in managed care plans, including materials and training specific to Medicaid, NJ FamilyCare, Medicare, and commercial managed care plans; (2) assist and educate individual enrollees about the functions of the State and federal agencies that regulate managed care products, assist and educate enrollees about the various complaint, grievance, and appeal processes, including State fair hearings, provide assistance to individuals in determining which process is most appropriate for the individual to pursue when necessary, maintain and provide to individual enrollees the forms that may be necessary to submit a complaint, grievance or appeal with the State or federal agencies, and provide assistance to individual enrollees in completion of the forms, if necessary; (3) maintain and provide information to individuals upon request about advocacy groups, including legal services programs Statewide and in each county that may be available to assist individuals, and maintain lists of State and Congressional representatives and the means by which to contact representatives, for distribution upon request; (4) maintain a toll-free telephone number for consumers to call for information and assistance. The number shall be accessible to the deaf and hard of hearing, and staff or translation services shall be available to assist non-English proficient individuals who are members of language groups that meet population thresholds established by the department; (5) ensure that individuals have timely access to the services of, and receive timely responses from, the program; (6) provide feedback to managed care plans, beneficiary advisory groups and employers regarding enrollees' concerns and problems; (7) provide nonpartisan information about federal and State activities relative to managed care, and provide assistance to individuals in obtaining copies of pending legislation, statutes, and regulations; and (8) develop and maintain a data base monitoring the degree of each type of service provided by the program to individual enrollees, the types of concerns and complaints brought to the program and the entities about which complaints and concerns are brought. c. In order to meet its objectives, the program shall have access to: (1) the medical and other records of an individual enrollee maintained by a managed care plan, upon the specific written authorization of the enrollee or his legal representative; (2) the administrative records, policies, and documents of managed care plans to which individuals or the general public have access; and (3) all licensing, certification, and data reporting records maintained by the State or reported to the federal government by the State that are not proprietary information or otherwise protected by law, with copies thereof to be supplied to the program by the State upon the request of the program. d. The program shall take such actions as are necessary to protect the identity and confidentiality of any complainant or other individual with respect to whom the program maintains files or records. Any medical or personally identifying information received or in the possession of the program shall be considered confidential and shall be used only by the department, the program and such other agencies as the commissioner designates and shall not be subject to public access, inspection or copying under P.L.1963, c.73 (C.47:1A-1 et seq.) or the common law concerning access to public records. This subsection shall not be construed to limit the ability of the program to compile and report non-identifying data pursuant to paragraph (8) of subsection b. of this section. e. The program shall seek to coordinate its activities with consumer advocacy organizations, legal assistance providers serving low-income and other vulnerable health care consumers, managed care and health insurance counseling assistance programs, and relevant federal and State agencies to assure that the information and assistance provided by the program are current and accurate. f. Until such time as the program is developed, the commissioner shall make agreements with two independent, private nonprofit consumer advocacy organizations, which shall be the Community Health Law Project and New Jersey Protection and Advocacy, Inc. to operate the program on an interim basis. The interim program shall be in effect for one year from the effective date of this act. Any appropriation in this act for the program may be allocated for the interim program. L.2001, c.14, s.3; amended 2012, c.17, s.303.
N.J. Stat. § 26:2S-22 Report to Governor, Legislature
4. The commissioner shall report to the Governor and the Legislature, no later than 18 months after the effective date of this act and annually thereafter, on the data collected by the program, the activities of the program and its effectiveness in meeting its objectives, including an evaluation of consumer problems, concerns and complaints, and shall accompany that report with any recommendations that the commissioner deems appropriate. L.2001,c.14,s.4.
N.J. Stat. § 26:2S-23 Immunity from liability
5. An employee, volunteer, board member or other representative of an organization selected by the commissioner pursuant to section 3 of this act shall be immune from liability for any action taken in the good faith performance of their official duties in connection with the program. L.2001,c.14,s.5.
N.J. Stat. § 26:2S-24 Appropriations; fees, use
6. a. There is appropriated $500,000 to the department from the General Fund to provide funding for the program, except that funds may be appropriated, in lieu of part or all of the amount appropriated from the General Fund, from the monies made available to the State from tobacco companies under the nationwide settlement of the respective actions by state governments against those companies. b. (1) The program may charge fees for the provision of materials to the public consistent with P.L.1963, c.73 (C.47:1A-1 et seq.). The commissioner may establish a separate fee schedule for training and education services that may be provided by the program to for-profit organizations, and for the distribution to nongovernmental entities of statistical information that may be developed by the program. (2) Revenues received by the department pursuant to paragraph (1) of this subsection shall be deposited into a special nonlapsing fund which the commissioner shall create in the department for the purpose of providing funding for the program, and these revenues and the interest earned therefrom shall be utilized to fund the program in addition to the amount appropriated pursuant to subsection b. of this section. L.2001,c.14,s.6.
N.J. Stat. § 26:2S-25 Rules, regulations.
8. The Commissioner of Banking and Insurance, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations to effectuate the purposes of this act. L.2001, c.14, s.8; amended 2012, c.17, s.304.
N.J. Stat. § 26:2S-26 Definitions relative to certain dental benefit plans.
1. As used in this act: "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization, or health maintenance organization, authorized to issue dental plans in this State. "Covered person" means a person on whose behalf a carrier offering a dental plan is obligated to pay benefits for or provide dental services pursuant to the plan. "Covered service" means a dental care service for which a reimbursement is available under a covered person's dental plan, or for which a reimbursement would be available but for the application of contractual limitations including, but not limited to, deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation, or services not reimbursable due to the dentist's failure to comply with a provision of the dentist's participating provider agreement or the dental plan. "Dental plan" means a benefits plan which pays or provides dental expense benefits for covered services and is delivered or issued for delivery in this State by or through a carrier either on a stand-alone basis or as part of other coverage including, but not limited to, health benefits coverage. L.2014, c.70, s.1.
N.J. Stat. § 26:2S-27 Covered services.
2. Notwithstanding section 22 of P.L.1993, c.162 (C.17B:27A-54) or any other law or regulation to the contrary, a contract between a carrier and a dentist to provide covered services shall not require, directly or indirectly, that a dentist provide services to a covered person at a fee set by, or at a fee subject to the approval of, the carrier unless the dental services are a covered service under the person's dental plan. L.2014, c.70, s.2.
N.J. Stat. § 26:2S-28 Rules, regulations.
3. The Commissioner of Banking and Insurance shall promulgate rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) necessary to effectuate the purposes of this act. L.2014, c.70, s.3.
N.J. Stat. § 26:2S-29 Carrier offering a health benefits plan to provide coverage, payment.
8. a. A carrier that offers a health benefits plan in this State shall provide coverage and payment for health care services delivered to a covered person through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered under the plan when delivered through in-person contact and consultation in New Jersey. Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate. b. A carrier may limit coverage to services that are delivered by health care providers in the health benefits plan's network, but may not charge any deductible, copayment, or coinsurance for a health care service, delivered through telemedicine or telehealth, in an amount that exceeds the deductible, copayment, or coinsurance amount that is applicable to an in-person consultation. In no case shall a carrier: (1) impose any restrictions on the location or setting of the distant site used by a health care provider to provide services using telemedicine and telehealth or on the location or setting of the originating site where the patient is located when receiving services using telemedicine and telehealth, except to ensure that the services provided using telemedicine and telehealth meet the same standard of care as would be provided if the services were provided in person; (2) restrict the ability of a provider to use any electronic or technological platform to provide services using telemedicine or telehealth, including, but not limited to, interactive, real-time, two-way audio, which may be used in combination with asynchronous store-and-forward technology without video capabilities, including audio-only telephone conversations, to provide services using telemedicine or telehealth, provided that the platform used: (a) allows the provider to meet the same standard of care as would be provided if the services were provided in person; and (b) is compliant with the requirements of the federal health privacy rule set forth at 45 CFR Parts 160 and 164; (3) deny coverage for or refuse to provide reimbursement for routine patient monitoring performed using telemedicine and telehealth, including remote monitoring of a patient's vital signs and routine check-ins with the patient to monitor the patient's status and condition, if coverage and reimbursement would be provided if those services are provided in person, and the provider is able to meet the same standard of care as would be provided if the services were provided in person; or (4) limit coverage only to services delivered by select third-party telemedicine or telehealth organizations. c. Nothing in this section shall be construed to: (1) prohibit a carrier from providing coverage for only those services that are medically necessary, subject to the terms and conditions of the covered person's health benefits plan; or (2) allow a carrier to require a covered person to use telemedicine or telehealth in lieu of receiving an in-person service from an in-network provider. d. The Commissioner of Banking and Insurance shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to implement the provisions of this section. e. As used in this section: "Asynchronous store-and-forward" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Carrier" means the same as that term is defined by section 2 of P.L.1997, c.192 (C.26:2S-2). "Covered person" means the same as that term is defined by section 2 of P.L.1997, c.192 (C.26:2S-2). "Distant site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Health benefits plan" means the same as that term is defined by section 2 of P.L.1997, c.192 (C.26:2S-2). "Originating site" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telehealth" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). "Telemedicine or telehealth organization" means the same as that term is defined by section 1 of P.L.2017, c.117 (C.45:1-61). L.2017, c.117, s.8; amended 2021, c.310, s.1.
N.J. Stat. § 26:2S-30 Definitions regarding dental plan application forms
1. As used in this act: "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization, or health maintenance organization, authorized to issue or act as an administrator of dental plans in this State. "Dental plan" means a benefits plan which pays or provides dental expense benefits for covered services and is delivered or issued for delivery in this State by or through a carrier either on a stand-alone basis or as part of other coverage including, but not limited to, health benefits coverage. L.2019, c.3, s.1.
N.J. Stat. § 26:2S-31 Adoption of dental plan application forms
2. a. The Commissioner of Banking and Insurance shall adopt by regulation a universal dentist application for participation form for use by carriers which offer or administer dental plans for the purpose of credentialing dentists who seek to participate in a carrier's provider network and for the purpose of credentialing dentists who are employed by hospitals or other health care facilities which seek to participate in a carrier's provider network. b. The commissioner shall also adopt by regulation a form for renewal of credentialing, which shall be an abbreviated version of the universal application form. The renewal form shall be designed to enable a dentist to indicate changes in the information provided in the application form. c. The commissioner shall revise the universal application and renewal forms, as necessary, to conform to industry-wide, national standards for credentialing. d. In developing the forms, the commissioner shall consult with the Commissioner of Human Services to ensure that the credentialing requirements for participation in the Medicaid program, established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), and the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.) are adequately reflected on the application and renewal forms. L.2019, c.3, s.2.
N.J. Stat. § 26:2S-32 Acceptance of universal dentist application
3. a. Within 180 days of the adoption of the forms by regulation pursuant to this act, a carrier which offers or administers a dental plan shall accept the universal dentist application for participation form and renewal form adopted pursuant to this act for the purpose of credentialing dentists who seek to participate in the carrier's provider network and for the purpose of credentialing dentists who are employed by hospitals or other health care facilities which seek to participate in the carrier's provider network. b. Nothing in this section shall be construed to prevent a carrier from requesting additional information from an applicant that is not provided for in the universal application or renewal form, as applicable, if the requested information does not duplicate any information included in the applicable form. L.2019, c.3, s.3.
N.J. Stat. § 26:2S-33 Adoption of regulations
4. The Commissioner of Banking and Insurance shall adopt regulations within 180 days of the date of enactment of this act, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of this act. L.2019, c.3, s.4.
N.J. Stat. § 26:2S-33.1 Carrier, participating dentist, agreement, collecting, covered procedures, services; refund, difference.
1. a. A carrier shall not include in an agreement between the carrier and a participating dentist a provision that prohibits a participating dentist from collecting an amount owed from a covered person for a covered procedure or service if the participating dentist: (1) notifies the covered person prior to performing the covered procedure or service that the dentist may not be paid by the carrier and that the covered person is responsible for payment of the covered procedure or service; (2) provides the covered person an explanation, in writing, of the benefits and material cost differences of suitable alternative options for the covered procedure or service, and that the alternative selected may not be covered by the plan, in advance of it being performed; (3) obtains the covered person's consent, in writing, to the performance of the covered procedure or service and the participating dentist makes the written consent available to the carrier upon request; and (4) accepts as payment in full the amount the participating dentist would have accepted from the carrier under the covered person's dental plan, including bundling pursuant to this act. A participating dentist that receives payment for a covered procedure or service from a covered person that exceeds the amount the participating dentist is obligated to accept under the covered person's dental plan shall refund to the covered person the difference between the amount accepted by the participating dentist from the covered person and the amount the participating dentist is obligated to accept under the covered person's dental plan. b. Notwithstanding the provisions of subsection a. of this section, this act shall not apply in cases where the service performed by the participating dentist is required as a result of a prior service by the dentist that was inconsistent with the quality of care in the practice of dentistry as determined by a licensed dentist, and this act shall not permit billing covered persons for: (1) equipment used by the participating dentist; (2) overhead expenses incurred by the participating dentist; (3) other costs of services or supplies rendered that are covered, or for which benefits are payable, under the covered person's dental plan, except for copayment, coinsurance, or deductible amounts set forth in the dental plan; or (4) laboratory costs or other services customarily associated with the performance of covered services unless: (a) the participating dentist receives prior written consent from the covered person in advance of the performance of the service; and (b) the participating dentist has explained, in writing, the benefits and material cost differences of suitable alternative options for the service, and that the alternative selected may not be covered by the plan, in advance of it being performed. c. A carrier shall not change a dentist's submitted procedure codes through down-coding or bundling unless the carrier undertakes a professional review of the submitted charges and supporting clinical information and determines that the original coding was incorrect, fragmented, or un-bundled as: (1) provided for in the Current Dental Terminology Code of Dental Procedures and Nomenclature; or (2) consistent with the generally acceptable standards of care in the practice of dentistry. d. Notwithstanding any other provision of this act or any other law to the contrary, a carrier may base its benefit reimbursement on a lower acceptable cost procedure, material, or test where an alternative, and less costly, means is available and generally accepted for purposes of benefit payment, and based on the participation agreement between the carrier and the participating dentist. However, nothing in this act shall preclude a carrier from covering procedures or services that are actually performed by a participating dentist, per its network provider agreement, and are otherwise eligible for benefit. e. Nothing in this act shall exempt or limit any dentist from the provisions of the "Insurance Fraud Prevention Act," P.L.1983, c.320 (C.17:33A-1 et seq.). f. As used in this act: "Bundling" means the practice of combining distinct dental procedures or components of a more extensive procedure into one procedure for billing purposes, but does not include the denial or adjustment of claims for covered services in accordance with the covered person's dental plan. "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, dental service corporation, dental plan organization or health maintenance organization authorized to issue dental contracts, policies, or plans in this State. "Covered person" means a person on whose behalf a carrier offering a dental plan is obligated to pay benefits for or provide dental procedures or services pursuant to the plan. "Covered procedure or service" means a dental care procedure or service that is consistent with generally acceptable standards of care in the practice of dentistry, and which the carrier has determined to be reimbursable under a covered person's dental plan, or for which a reimbursement would be available but for the application of deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, or alternative benefit payments. "Dental plan" means a benefits plan, policy, or contract which pays or provides dental expense benefits for covered procedures or services and is delivered or issued for delivery in this State by or through a carrier either on a stand-alone basis or as part of other coverage including, but not limited to, health benefits coverage. Dental plan shall not include the following plans, policies, or contracts: accident only, credit disability, long-term care, Medicare supplement coverage; TRICARE supplement coverage, coverage for Medicare services pursuant to a contract with the United States government, the State Medicaid program established pursuant to 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.), coverage arising out of a worker's compensation or similar law, the State Health Benefits Program, the School Employees' Health Benefits Program, or a self-insured health benefits plan governed by the provisions of the federal "Employee Retirement Income Security Act of 1974," 29 U.S.C. s.1001 et seq., coverage under a policy of private passenger automobile insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage. "Down-coding" means the adjustment of a claim submitted to a dental plan to a less complex or lower cost procedure code. Down-coding does not include a carrier's adjustment of payment for procedures which were improperly or inaccurately billed, or the denial or adjustment of claims for covered services in accordance with the covered person's dental plan. "Participating dentist" means a dentist who has entered into a contract with a carrier to provide dental services to covered persons for a predetermined fee or set of fees. L.2023, c.207.
N.J. Stat. § 26:2S-34 Preexisting condition provision prohibited in health benefits plan.
6. A carrier that offers a health benefits plan in this State shall ensure that the plan does not contain any provision that: a. denies or limits benefits for a preexisting condition to any covered person; or b. uses a preexisting condition as a factor in calculating a premium. L.2019, c.253, s.6.
N.J. Stat. § 26:2S-35 Imposition of limits prohibited.
4. Notwithstanding any law to the contrary, a health benefits plan shall not impose: (1) any lifetime limits on the dollar value of benefits for any individual insured pursuant to the plan; or (2) any annual limits on the dollar value of essential health benefits. L.2019, c.354, s.4.
N.J. Stat. § 26:2S-36 Provision of emergency, urgent services.
5. A carrier that offers a health benefits plan in this State shall provide that coverage for medically necessary services on an emergency or urgent basis shall be provided without imposing any requirement under the plan for prior authorization of the services or, if the services are provided by an out-of-network provider, any limitation on coverage that is more restrictive than if the services were provided by an in-network provider. L.2019, c.354, s.5.
N.J. Stat. § 26:2S-37 Insurance plans to cover prescription refills during state of emergency.
2. a. Subject to subsection b. of this section and to the extent consistent with clinical guidelines, the Commissioner of Banking and Insurance shall require carriers to provide coverage of prescription drug refills even when the covered person has not yet reached the scheduled refill date, provided that the prescription itself would remain valid beyond the refill date and the member will be eligible beyond the refill date, in a manner calculated to ensure a subscriber's ability to maintain at least a 30-day supply, or a 90-day supply of a maintenance medication supply at home but not to exceed a 120-day supply on-hand at any given time. The coverage shall be provided based on the authorization for the most recently filled prescription and additional authorization for the refill shall not be required. b. The provisions of this section shall be in effect if: (1) a state of emergency or public health emergency is declared by the State or federal government, or an emergency supply of a drug is recommended by the Centers for Disease Control and Prevention; and
(2) the commissioner determines that an emergency supply of prescription drugs is necessary. c. The coverage shall be provided on an in-network basis to the same extent as for any other refills of prescription drugs under the health benefits plan, except that: (1) in the event of a drug shortage or access issue identified by the commissioner or the Division of Consumer Affairs, the carrier shall provide formulary flexibility for a covered alternative. The cost-sharing for any non-preferred medication shall not exceed the cost-sharing that would be imposed for the preferred medication that is unavailable due to the shortage or access issue; and (2) no fees shall be imposed for home delivery of the drugs. d. The Division of Consumer Affairs, in consultation with the commissioner, may develop restrictions on the filling or refilling of prescriptions by pharmacists to address shortage concerns, provided those restrictions shall exclude restricting use for existing conditions to the maximum extent practicable.
e. As used in this section, "carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, and shall include the State Health Benefits Program and the School Employees' Health Benefits Program. L.2020, c.30, s.2.
N.J. Stat. § 26:2S-38 Prescription drug benefit carrier contracts, opioid antidote coverage.
1. a. A carrier shall ensure that every contract to provide prescription drug benefits, or to authorize the purchase of a contract to provide prescription drug benefits, shall provide coverage for an opioid antidote to covered persons without the imposition of any prior authorization or other utilization management requirements, provided that the drug is: (1) prescribed or administered to the covered person by a licensed medical practitioner who is authorized to prescribe or administer that treatment pursuant to State and federal law; or (2) dispensed to the covered person by a licensed pharmacist under a standing order to dispense an opioid antidote pursuant to section 1 of P.L.2017, c.88 (C.45:14-67.2). b. The provisions of this section shall not be construed to limit the coverage of an opioid antidote only when administered by a medical practitioner. c. As used in this section: "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State. "Opioid antidote" means naloxone hydrochloride, or any other similarly acting drug approved by the United States Food and Drug Administration for self-administration for the treatment of an opioid overdose. L.2021, c.157, s.1.
N.J. Stat. § 26:2S-39 Health benefit plans, coverage for abortion, certain religious employers exempt.
3. a. Upon concluding a study and issuing a report to the Governor and the Legislature demonstrating that such a regulation is necessary, the Department of Banking and Insurance may, through regulation adopted pursuant to the "Administrative Procedure Act", P.L.1968 c.410 (C.52:14B-1 et seq.), provide that health benefit plans delivered, issued, executed, or renewed in this State, provide coverage for abortion. If the department provides for coverage pursuant to this section, then the department shall also require carriers to grant, upon request of a religious employer, an exclusion under the contract for the coverage required 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 covered persons and prospective covered persons, and the carrier shall provide notice to the Commissioner of Banking and Insurance in such form and manner as may be determined by the commissioner. The provisions of this paragraph shall not be construed as authorizing a carrier to exclude coverage for care that is necessary to preserve the life or health of a subscriber. An exclusion from an insurance coverage mandate granted to a religious employer pursuant to this section shall not be considered a violation of section 2 of P.L.2021, c.375 (C.10:7-2). b. For the purposes of this section, "religious employer" means an organization that is organized and operates as a nonprofit entity and is referred to in section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986 (26 U.S.C. s.6033), as amended. L.2021, c.375, s.3.
N.J. Stat. § 26:2S-40 Carrier to ensure provision of comprehensive behavioral health crisis intervention services coverage.
8. A carrier that offers a health benefits plan in this State shall ensure that the plan provides comprehensive coverage for behavioral health crisis intervention services provided pursuant to section 3 of P.L.2022, c.35 (C.26:2MM7) under the same terms and conditions as provided for any other sickness under the plan 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). L.2022, c.35, s.8.
N.J. Stat. § 26:2S-41 Coverage for screening, prevention, treatment services of behavioral health issues in children.
1. a. A carrier that offers a health benefits plan in this State shall provide benefits to any subscriber for medical expenses incurred in screening, prevention, and treatment services of behavioral health issues in children. A carrier shall accept and reimburse claims for screening, prevention, and treatment using an at-risk diagnosis. b. The benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract. c. As used in this section: “At-risk diagnosis” means a diagnosis made after consideration of factors influencing behavioral health and child development, such as family circumstances or life challenges, that does not lead to a formal mental health diagnosis and, instead, promotes preventive care. Allowing providers to bill for an “at-risk diagnosis” authorizes providers to use an alternative code, including a Social Determinants of Health Z-code, to the codes of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders or the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood when billing for services, without a formal mental health diagnosis, for children who are 18 years of age or younger. "Carrier" means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State. “Screening, prevention, and treatment” includes the prevention and early identification of mental health conditions without a behavioral health diagnosis. Services may include, but are not limited to, screenings and individual, group, and family psychotherapy to individuals with potential mental health disorders not yet diagnosed. L.2025, c.369, s.1.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://www.njleg.state.nj.us/legislative-activity/statutesFetched: 10/17/2026