Bill Text: NJ A4273 | 2024-2025 | Regular Session | Introduced
Bill Title: Requires Medicaid provide health benefits coverage, and places certain requirements on insurers and State Health Benefits Program regarding existing mandate on health benefits coverage, for certain over-the-counter contraceptives.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced) 2024-05-02 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A4273 Detail]
Download: New_Jersey-2024-A4273-Introduced.html
Sponsored by:
Assemblywoman LISA SWAIN
District 38 (Bergen)
Assemblywoman VERLINA REYNOLDS-JACKSON
District 15 (Hunterdon and Mercer)
SYNOPSIS
Requires Medicaid provide health benefits coverage, and places certain requirements on insurers and State Health Benefits Program regarding existing mandate on health benefits coverage, for certain over-the-counter contraceptives.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits coverage for certain contraceptives and amending various parts of statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 6 of P.L.1968, c.413 (C.30:4D-6) is amended to read as follows:
6. a. Subject to the requirements of Title XIX of the federal Social Security Act, the limitations imposed by this act and by the rules and regulations promulgated pursuant thereto, the department shall provide medical assistance to qualified applicants, including authorized services within each of the following classifications:
(1) Inpatient hospital services
(2) Outpatient hospital services;
(3) Other laboratory and X-ray services;
(4) (a) Skilled nursing or intermediate care facility services;
(b) Early and periodic screening and diagnosis of individuals who are eligible under the program and are under age 21, to ascertain their physical or mental health status and the health care, treatment, and other measures to correct or ameliorate defects and chronic conditions discovered thereby, as may be provided in regulation of the Secretary of the federal Department of Health and Human Services and approved by the commissioner;
(5) Physician's services furnished in the office, the patient's home, a hospital, a skilled nursing, or intermediate care facility or elsewhere.
As used in this subsection, "laboratory and X-ray services" includes HIV drug resistance testing, including, but not limited to, genotype assays that have been cleared or approved by the federal Food and Drug Administration, laboratory developed genotype assays, phenotype assays, and other assays using phenotype prediction with genotype comparison, for persons diagnosed with HIV infection or AIDS.
b. Subject to the limitations imposed by federal law, by this act, and by the rules and regulations promulgated pursuant thereto, the medical assistance program may be expanded to include authorized services within each of the following classifications:
(1) Medical care not included in subsection a.(5) above, or any other type of remedial care recognized under State law, furnished by licensed practitioners within the scope of their practice, as defined by State law;
(2) Home health care services;
(3) Clinic services;
(4) Dental services;
(5) Physical therapy and related services;
(6) Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist, whichever the individual may select;
(7) Optometric services;
(8) Podiatric services;
(9) Chiropractic services;
(10) Psychological services;
(11) Inpatient psychiatric hospital services for individuals under 21 years of age, or under age 22 if they are receiving such services immediately before attaining age 21;
(12) Other diagnostic, screening, preventative, and rehabilitative services, and other remedial care;
(13) Inpatient hospital services, nursing facility services, and immediate care facility services for individuals 65 years of age or over in an institution for mental diseases;
(14) Intermediate care facility services;
(15) Transportation services;
(16) Services in connection with the inpatient or outpatient treatment or care of substance use disorder, when the treatment is prescribed by a physician and provided in a licensed hospital or in a narcotic and substance use disorder treatment center approved by the Department of Health pursuant to P.L.1970, c.334 (C.26:2G-21 et. seq.) and whose staff includes a medical director, and limited those services eligible for federal financial participation under Title XIX of the federal Social Security Act;
(17) Any other medical care and any other type of remedial care recognized under State law, specified by the Secretary of the federal Department of Health and Human Services, and approved by the commissioner;
(18) Comprehensive maternity care, which may include: the basic number of prenatal and postpartum visits recommended by the American College of Obstetrics and Gynecology; additional prenatal and postpartum visits that are medically necessary; necessary laboratory, nutritional assessment and counseling, health education, personal counseling, managed care, outreach, and follow-up services; treatment of conditions which may complicate pregnancy doula care; and physician or certified nurse midwife delivery services. For the purposes of this paragraph, "doula" means a trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth, to help her to achieve the healthiest, most satisfying experience possible;
(19) Comprehensive pediatric care, which may include: ambulatory, preventive, and primary care health services. The preventive services shall include, at a minimum, the basic number of preventive visits recommended by the American Academy of Pediatrics;
(20) Services provided by a hospice which is participating in the Medicare program established pursuant to Title XVIII of the Social Security Act, Pub.L.89-97 (42 U.S.C. s.1395 et seq.). Hospice services shall be provided subject to approval of the Secretary of the federal Department of Health and Human Services for federal reimbursement;
(21) Mammograms, subject to approval of the Secretary of the federal Department of Health and Human Services for federal reimbursement, including one baseline mammogram for women who are at least 35 but less than 40 years of age; one mammogram examination every two years or more frequently, if recommended by a physician, for women who are at least 40 but less than 50 years of age; and one mammogram examination every year for women age 50 and over;
(22) Upon referral by a physician, advanced practice nurse, or physician assistant of a person who has been diagnosed with diabetes, gestational diabetes, or pre-diabetes, in accordance with standards adopted by the American Diabetes Association:
(a) Expenses for diabetes self-management education or training to ensure that a person with diabetes, gestational diabetes, or pre-diabetes can optimize metabolic control, prevent and manage complications, and maximize quality of life. Diabetes self-management education shall be provided by an in-State provider who is:
(i) a licensed, registered, or certified health care professional who is certified by the National Certification Board of Diabetes Educators as a Certified Diabetes Educator, or certified by the American Association of Diabetes Educators with a Board Certified-Advanced Diabetes Management credential, including, but not limited to: a physician, an advanced practice or registered nurse, a physician assistant, a pharmacist, a chiropractor, a dietitian registered by a nationally recognized professional association of dietitians, or a nutritionist holding a certified nutritionist specialist (CNS) credential from the Board for Certification of Nutrition Specialists; or
(ii) an entity meeting the National Standards for Diabetes Self-Management Education and Support, as evidenced by a recognition by the American Diabetes Association or accreditation by the American Association of Diabetes Educators;
(b) Expenses for medical nutrition therapy as an effective component of the person's overall treatment plan upon a: diagnosis of diabetes, gestational diabetes, or pre-diabetes; change in the beneficiary's medical condition, treatment, or diagnosis; or determination of a physician, advanced practice nurse, or physician assistant that reeducation or refresher education is necessary. Medical nutrition therapy shall be provided by an in-State provider who is a dietitian registered by a nationally-recognized professional association of dietitians, or a nutritionist holding a certified nutritionist specialist (CNS) credential from the Board for Certification of Nutrition Specialists, who is familiar with the components of diabetes medical nutrition therapy;
(c) For a person diagnosed with pre-diabetes, items and services furnished under an in-State diabetes prevention program that meets the standards of the National Diabetes Prevention Program, as established by the federal Centers for Disease Control and Prevention; and
(d) Expenses for any medically appropriate and necessary supplies and equipment recommended or prescribed by a physician, advanced practice nurse, or physician assistant for the management and treatment of diabetes, gestational diabetes, or pre-diabetes, including, but not limited to: equipment and supplies for self-management of blood glucose; insulin pens; insulin pumps and related supplies; and other insulin delivery devices;
(23) Expenses incurred for the provision of group prenatal services to a pregnant woman, provided that:
(a) the provider of such services, which shall include, but not be limited to, a federally qualified health center or a community health center operating in the State:
(i) is a site accredited by the Centering Healthcare Institute, or is a site engaged in an active implementation contract with the Centering Healthcare institute, that utilizes the Centering Pregnancy model; and
(ii) incorporates the applicable information outlined in any best practices manual for prenatal and postpartum maternal care developed by the Department of Health into the curriculum for each group prenatal visit;
(b) each group prenatal care visit is at least 1.5 hours in duration, with a. minimum of two women and a maximum of 20 women in participation; and
(c) no more than 10 group prenatal care visits occur per pregnancy. As used in this paragraph, "group prenatal care services" means a series of prenatal care visits provided in a group setting which are based upon the Centering Pregnancy model developed by the Centering Healthcare Institute and which include health assessments, social and clinical support, and educational activities;
(24) Expenses incurred for the provision of pasteurized donated human breast milk, which shall include human milk fortifiers if indicated in a medical order provided by a licensed medical practitioner, to an infant under the age of six months; provided that the milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health and a licensed medical practitioner has issued a medical order for the infant under at least one of the following circumstances:
(a) the infant is medically or physically unable to receive maternal breast milk or participate in breast feeding, or the infant's mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or
(b) the infant meets any of the following conditions:
(i) a body weight below healthy levels, as determined by the licensed medical practitioner issuing the medical order for the infant;
(ii) the infant has a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis; or
(iii) the infant has a congenital or acquired condition that may benefit from the use of donor breast milk and human milk fortifiers, as determined by the Department of Health;
(25) Comprehensive tobacco cessation benefits to an individual who is 18 years of age or older, or who is pregnant. Coverage shall include: brief and high intensity individual counseling, brief and high intensity group counseling, and telemedicine as defined by section 1 of P.L.2017, c.117 (C.45:1-61); all medications approved for tobacco cessation by the U.S. Food and Drug Administration; and other tobacco cessation counseling recommended by the Treating Tobacco Use and Dependence Clinical Practice Guideline issued by the U.S. Public Health Service. Notwithstanding the provisions of any other law, rule, or regulation to the contrary, and except as otherwise provided in this section:
(a) Information regarding the availability of the tobacco cessation services described in this paragraph shall be provided to all individuals authorized to receive the tobacco cessation services pursuant to this paragraph at the following times: no later than 90 days after the effective date of P.L.2019, c.473: upon the establishment of an individual's eligibility for medical assistance; and upon the redetermination of an individual's eligibility for medical assistance;
(b) The following conditions shall not be imposed on any tobacco cessation services provided pursuant to this paragraph: copayments or any other forms of cost-sharing, including deductibles; counseling requirements for medication; stepped care therapy or similar restrictions requiring the use of one service prior to another; limits on the duration of services; or annual or lifetime limits on the amount, frequency, or cost of services, including, but not limited to, annual or lifetime limits on the number of covered attempts to quit; and
(c) Prior authorization requirements shall not be imposed on any tobacco cessation services provided pursuant to this paragraph except in the following circumstances where prior authorization may be required: for a treatment that exceeds the duration recommended by the most recently published United States Public Health Service clinical practice guidelines on treating tobacco use and dependence; or for services associated with more than two attempts to quit within a 12-month period;
(26) Provided that there is federal financial participation available, benefits for expenses incurred in conducting a colorectal cancer screening in accordance with United States Preventive Services Task Force recommendations. The method and frequency of screening to be utilized shall be in accordance with the most recent published recommendations of the United States Preventive Services Task Force and as determined medically necessary by the covered person's physician, in consultation with the covered person.
No deductible, coinsurance, copayment, or any other cost-sharing requirement shall be imposed for a colonoscopy performed following a positive result on a non-colonoscopy, colorectal cancer screening test recommended by the United States Preventive Services Task Force; [and]
(27) (a) Within 24 months of the effective date of P.L.2023, c.187 (C.30:4D-6u et al.), and conditional on the receipt of all necessary federal approvals and the securing of federal financial participation pursuant to section 2 of P.L.2023, c.187 (C.30:4D-6u), community-based palliative care benefits which shall include, but not be limited to, all of the following:
(i) specialized medical care and emotional and spiritual support for beneficiaries with serious advanced illnesses;
(ii) relief of symptoms, pain, and stress of serious illness;
(iii) improvement of quality of life for both the beneficiary and the beneficiary's family; and
(iv) appropriate care for any age and for any stage of serious illness, along with curative treatment.
(b) Benefits provided under this paragraph shall include, but shall not be limited to, services provided by a hospice pursuant to paragraph (20) of subsection b. of this section, provided that:
(i) hospice services may be provided at the same time that curative treatment is available, to the extent that services are not duplicative;
(ii) hospice services may be provided to beneficiaries whose conditions may result in death, regardless of the estimated length of the beneficiary's remaining period of life; and
(iii) the Division of Medical Assistance and Health Services in the Department of Human Services may include any other service deemed appropriate under the benefits provided under this paragraph.
(c) Providers authorized to deliver benefits provided under this paragraph shall include Medicaid-approved licensed hospice agencies, Medicaid-approved home health agencies licensed to provide hospice care, and other Medicaid-approved licensed health care providers.
(d) Nothing in this paragraph shall be construed to result in the elimination or reduction of covered benefits or services under the Medicaid program.
(e) This paragraph shall not affect a beneficiary's eligibility to receive, concurrently with services provided for in this paragraph, any services, including home health services, for which the beneficiary would have been eligible in the absence of this paragraph, to the extent that services are not duplicative; and
(28) (a) All female contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration, regardless of whether the contraceptive drug is dispensed pursuant to a prescription. Coverage under this paragraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this paragraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph.
(b) The department shall establish mechanisms to ensure that a qualified applicant who is eligible for coverage of a contraceptive drug under this paragraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make a purchase of a contraceptive drug with a payment at the point of sale and submit a claim for reimbursement to the department.
c. Payments for the foregoing services, goods and supplies furnished pursuant to this act shall be made to the extent authorized by this act, the rules and regulations promulgated pursuant thereto and, where applicable, subject to the agreement of insurance provided for under this act. The payments shall constitute payment in full to the provider on behalf of the recipient. Every provider making a claim for payment pursuant to this act shall certify in writing on the claim submitted that no additional amount will be charged to the recipient, the recipient's family, the recipient's representative or others on the recipient's behalf for the services, goods, and supplies furnished pursuant to this act.
No provider whose claim for payment pursuant to this act has been denied because the services, goods, or supplies were determined to be medically unnecessary shall seek reimbursement form the recipient, his family, his representative or others on his behalf for such services, goods, and supplies provided pursuant to this act; provided, however, a provided may seek reimbursement from a recipient for services, goods, or supplies not authorized by this act, if the recipient elected to receive the services, goods or supplies with the knowledge that they were not authorized.
d. Any individual eligible for medical assistance (including drugs) may obtain such assistance from any person qualified to 33 perform the service or services required (including an organization which provides such services, or arranges for their availability on a prepayment basis), who undertakes to provide the individual such services.
No copayment or other form of cost-sharing shall be imposed on any individual eligible for medical assistance, except as mandated by federal law as a condition of federal financial participation.
e. Anything in this act to the contrary notwithstanding, no payments for medical assistance shall be made under this act with respect to care or services for any individual who:
(1) Is an inmate of a public institution (except as a patient in a medical institution); provided, however, that an individual who is otherwise eligible may continue to receive services for the month in which he becomes an inmate, should the commissioner determine to expand the scope of Medicaid eligibility to include such an individual, subject to the limitations imposed by federal law and regulations, or
(2) Has not attained 65 years of age and who is a patient in an institution for mental diseases, or
(3) Is over 21 years of age and who is receiving inpatient psychiatric hospital services in a psychiatric facility; provided, however, that an individual who was receiving such services immediately prior to attaining age 21 may continue to receive such services until the individual reaches age 22. Nothing in this subsection shall prohibit the commissioner from extending medical assistance to all eligible persons receiving inpatient psychiatric services; provided that there is federal financial participation available.
f. (1) A third party as defined in section 3 of P.L.1968, c.413 (C.30:4D-3) shall not consider a person's eligibility for Medicaid in this or another state when determining the person's eligibility for enrollment or the provision of benefits by that third party.
(2) In addition, any provision in a contract of insurance, health benefits plan, or other health care coverage document, will, trust, agreement, court order, or other instrument which reduces or excludes coverage or payment for health care-related goods and services to or for an individual because of that individual's actual or potential eligibility for or receipt of Medicaid benefits shall be null and void, and no payments shall be made under this act as a result of any such provision.
(3) Notwithstanding any provision of law to the contrary, the provisions of paragraph (2) of this subsection shall not apply to a trust agreement that is established pursuant to 42 U.S.C. s.1396p(d)(4)(A) or (C) to supplement and augment assistance provided by government entities to a person who is disabled as defined in section 1614(a)(3) of the federal Social Security Act (42 31 U.S.C. s.1382c (a)(3)).
g. The following services shall be provided to eligible medically needy individuals as follows:
(1) Pregnant women shall be provided prenatal care and delivery services and postpartum care, including the services cited in subsections a.(1), (3), and (5) of this section and subsections b.(1)-(10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section.
(2) Dependent children shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1), (2), (3), (4), (5), (6), (7), (10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section.
(3) Individuals who are 65 years of age or older shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section.
(4) Individuals who are blind or disabled shall be provided with services cited in subsections a.(3) and (5) of this section and subsections b.(1)-(5), (6) excluding prescribed drugs, (7), (8), (10), 3 (12), (15), and (17) of this section, and nursing facility services cited in subsection b.(13) of this section.
(5) (a) Inpatient hospital services, subsection a.(1) of this section, shall only be provided to eligible medically needy individuals, other than pregnant women, if the federal Department of Health and Human Services discontinues the State's waiver to establish inpatient hospital reimbursement rates for the Medicare and Medicaid programs under the authority of section 601(c)(3) of the Social Security Act Amendments of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)). Inpatient hospital services may be extended to other eligible medically needy individuals if the federal Department of Health and Human Services directs that these services be included.
(b) Outpatient hospital services, subsection a.(2) of this section, shall only be provided to eligible medically needy individuals if the federal Department of Health and Human Services discontinues the State's waiver to establish outpatient hospital reimbursement rates for the Medicare and Medicaid programs under the authority of section 601(c)(3) of the Social Security Amendments of 1983, Pub.L.98-21 (42 U.S.C. s.1395ww(c)(5)). Outpatient hospital services may be extended to all or to certain medically needy individuals if the federal Department of Health and Human Services directs that these services be included. However, the use of outpatient hospital services shall be limited to clinic services and to emergency room services for injuries and significant acute medical conditions.
(c) The division shall monitor the use of inpatient and outpatient hospital services by medically needy persons.
h. In the case of a qualified disabled and working individual pursuant to section h6408 of Pub.L.101-239 (42 U.S.C. s.1396d), the only medical assistance provided under this act shall be the payment of premiums for Medicare part A under 42 U.S.C. ss.1395i-2 and 1395r.
i. In the case of a specified low-income Medicare beneficiary pursuant to 42 U.S.C. s.1396a(a)10(E)iii, the only medical assistance provided under this act shall be the payment of premiums for Medicare part B under 42 U.S.C. s.1395r as provided for in 42 U.S.C. s.1396d(p)(3)(A)(ii).
j. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(aa), the only medical assistance provided under this act shall be payment for authorized services provided during the period in which the individual requires treatment for breast or cervical cancer, in accordance with criteria established by the commissioner.
k. In the case of a qualified individual pursuant to 42 U.S.C. s.1396a(ii), the only medical assistance provided under this act shall be payment for family planning services and supplies as described at 42 U.S.C. s.1396d(a)(4)(C), including medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting.
(cf: P.L.2023, c.187, s.1)
2. Section 1 of P.L.2023, c.2 (C.45:14-67.9) is amended to read as follows:
1. a. Notwithstanding any other law to the contrary, a pharmacist shall be authorized to furnish self-administered hormonal contraceptives to a patient, in accordance with standardized procedures and protocols to be jointly developed and approved by the Board of Pharmacy and the State Board of Medical Examiners, in consultation with the American Congress of Obstetricians and Gynecologists, the New Jersey Pharmacists Association, and other appropriate entities, and in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) and the provisions of this subsection.
b. At a minimum, the standardized procedures and protocols adopted under this subsection shall:
(1) require a pharmacist, as a condition of furnishing self-administered hormonal contraceptives to patients pursuant to this section, to:
(i) complete a training program jointly approved by the Board of Pharmacy and the State Board of Medical Examiners; and
(ii) affirm, in writing, that he or she has completed appropriate training and will follow pertinent guidelines offered by the federal Centers for Disease Control and Prevention, including the United States Medical Eligibility Criteria for Contraceptive Use, which written affirmation shall be retained by the pharmacist as a medical record, in a manner and for such periods of time, as required by law;
(2) provide for the issuance of a standing order authorizing pharmacists in this State to furnish self-administered hormonal contraceptives to patients without an individual prescription;
(3) identify the self-administered hormonal contraceptives that a pharmacist will be authorized to furnish to patients pursuant to the standing order;
(4) require a pharmacist to make clinical decisions that are free from any financial influence imposed by insurance providers, contraceptive product manufacturers, and other parties having a financial interest in the disbursement or non-disbursement of self-administered hormonal contraceptives;
(5) require a patient, prior to obtaining a self-administered hormonal contraceptive pursuant to this section, to be evaluated through the administration of a questionnaire by the dispensing pharmacist, which questionnaire shall be developed by the Department of Health, that will identify patient risk factors for the use of self-administered hormonal contraceptives, based on the current United States Medical Eligibility Criteria for Contraceptive Use. The patient's responses to the written questionnaire shall be retained as a medical record, in a manner and for such periods of time, as required by law;
(6) require a pharmacist to offer to provide counseling to a patient about other forms of contraception that have been approved by the [federal] United States Food and Drug Administration, and, if the patient accepts the offer for counseling, require the pharmacist to provide the patient with specific and appropriate information about such other forms of contraception, based on the results of the questionnaire administered pursuant to paragraph (5) of this subsection; and
(7) require a pharmacist, upon furnishing a self-administered hormonal contraceptive to a patient, or upon determining that a self-administered hormonal contraceptive is not recommended, to refer the patient to the patient's primary care provider, or, if the patient does not have a primary care provider, to an appropriate and nearby medical clinic.
c. The Board of Pharmacy and the Board of Medical Examiners are each authorized to ensure compliance with the provisions of this section, and each board is specifically charged with the enforcement of this section as applied to its respective licensees.
d. As used in this section, "self-administered hormonal contraceptive" means any oral, transdermal, or vaginal contraceptive product, including, but not limited to, birth control pills, vaginal rings, and diaphragms.
e. Nothing in this section shall be construed to expand the authority of a pharmacist to prescribe any prescription medication. The requirements of this section shall not apply to a pharmacist dispensing a self-administered hormonal contraceptive pursuant to an individual prescription issued by a health care practitioner authorized to prescribe self-administered hormonal contraceptives in the course of professional practice, or to a pharmacist dispensing a female contraceptive drug available for over-the-counter sale that is approved by the United States Food and Drug Administration.
(cf: P.L.2023, c.2, s.1)
3. Section 2 of P.L.2023, c.2 (C.45:14-67.10) is amended to read as follows:
2. The Commissioner of Health, in consultation with the Commissioner of Human Services, shall establish a public awareness campaign to inform the general public concerning the ability to obtain self-administered hormonal contraceptives from a pharmacy without an individual prescription pursuant to the provisions of section 1 of P.L.2023, c.2 (C.45:14-67.9), as well as the availability of health benefits coverage for female contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration under Medicaid, the State Health Benefits Program, the School Employees' Health Benefits Program, and other health benefits plans. There shall be appropriated to the Department of Health such funding as shall be necessary to implement the provisions of this section.
(cf: P.L.2023, c.2, s.2)
4. Section 1 of P.L.2005, c.251 (C.17:48-6ee) is amended to read as follows:
1. a. A hospital service corporation that provides hospital or medical expense benefits shall provide coverage under every contract delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A hospital service corporation shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the hospital service corporation.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to those contracts in which the hospital service corporation has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.1)
5. Section 2 of P.L.2005, c.251 (C.17:48A-7bb) is amended to read as follows:
2. a. A medical service corporation that provides hospital or medical expense benefits shall provide coverage under every contract delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A medical service corporation shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the medical service corporation.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to those contracts in which the medical service corporation has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.2)
6. Section 3 of P.L.2005, c.251 (C.17:48E-35.29) is amended to read as follows:
3. a. A health service corporation that provides hospital or medical expense benefits shall provide coverage under every contract delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A health service corporation shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the health service corporation.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to those contracts in which the health service corporation has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.3)
7. Section 4 of P.L.2005, c.251 (C.17B:27-46.1ee) is amended to read as follows:
4. a. A group health insurer that provides hospital or medical expense benefits shall provide coverage under every policy delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A group health insurer shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the group health insurer.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the policy, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.4)
8. Section 5 of P.L.2005, c.251 (C.17B:26-2.1y) is amended to read as follows:
5. a. An individual health insurer that provides hospital or medical expense benefits shall provide coverage under every policy delivered, issued, executed or renewed in this State or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A individual health insurer shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the individual health insurer.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the policy, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to those policies in which the insurer has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c. 376, s.5)
9. Section 6 of P.L.2005, c.251 (C.26:2J-4.30) is amended to read as follows:
6. a. A certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued on or after the effective date of this act for a health maintenance organization, unless the health maintenance organization provides health care services for prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A health maintenance organization shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the health maintenance organization.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the health care services shall be provided to the same extent as for any other service, drug, device, product, or procedure under the contract, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. The provisions of this section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.6)
10. Section 7 of P.L.2005, c.251 (C.17B:27A-7.12) is amended to read as follows:
7. a. An individual health benefits plan required pursuant to section 3 of P.L.1992, c.161 (C.17B:27A-4) shall provide coverage for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. An individual health benefits plan shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the individual health benefits plan.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the health benefits plan, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.7)
11. Section 8 of P.L.2005, c.251 (C.17B:27A-19.15) is amended to read as follows:
8. a. A small employer health benefits plan required pursuant to section 3 of P.L.1992, c.162 (C.17B:27A-19) shall provide coverage for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. A small employer health benefits plan shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the small employer health benefits plan.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the benefits shall be provided to the same extent as for any other service, drug, device, product, or procedure under the health benefits plan, except no deductible, coinsurance, copayment, or any other cost-sharing requirement on the coverage shall be imposed.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. This section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
e. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2021, c.376, s.8)
12. Section 10 of P.L.2005, c.251 (C.52:14-17.29j) is amended to read as follows:
10. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act shall provide benefits for expenses incurred in the purchase of prescription female contraceptives, and the following services, drugs, devices, products, and procedures on an in-network basis:
(1) Any contraceptive drug, device or product approved by the United States Food and Drug Administration, which coverage shall be subject to all of the following conditions:
(a) If there is a therapeutic equivalent of a contraceptive drug, device or product approved by the United States Food and Drug Administration, coverage shall be provided for either the requested contraceptive drug, device or product or for one or more therapeutic equivalents of the requested drug, device or product.
(b) Coverage shall be provided without a prescription for all contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration. Coverage under this subparagraph shall be provided: (i) for the furnishing of a contraceptive drug intended to last for a 12-month period; and (ii) without any deductible, coinsurance, copayment, or other cost-sharing requirement. If the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions in accordance with this subparagraph shall not be required, as long as at least one drug is covered without any deductible, coinsurance, copayment, or other cost-sharing requirement in accordance with this paragraph. The State Health Benefits Commission shall establish mechanisms to ensure that an enrollee who is eligible for coverage of a contraceptive drug under this subparagraph has the option either to access the contraceptive drug at a pharmacy without a payment required at the point of sale or to make the purchase with a payment at the point of sale and submit a claim for reimbursement to the State Health Benefits Commission.
(c) Coverage shall be provided without any infringement upon a subscriber's choice of contraception and medical necessity shall be determined by the provider for covered contraceptive drugs, devices or other products approved by the United States Food and Drug Administration.
(2) Voluntary male and female sterilization.
(3) Patient education and counseling on contraception.
(4) Services related to the administration and monitoring of drugs, devices, products and services required under this section, including but not limited to:
(a) Management of side effects;
(b) Counseling for continued adherence to a prescribed regimen;
(c) Device insertion and removal;
(d) Provision of alternative contraceptive drugs, devices or products deemed medically appropriate in the judgment of the subscriber's health care provider; and
(e) Diagnosis and treatment services provided pursuant to, or as a follow-up to, a service required under this section.
b. The coverage provided shall include prescriptions for dispensing contraceptives for:
(1) (Deleted by amendment, P.L.2021, c.376)
(2) up to a 12-month period at one time.
c. (1) Except as provided in paragraph (2) of this subsection, the contract shall specify that no deductible, coinsurance, copayment, or any other cost-sharing requirement may be imposed on the coverage required pursuant to this section.
(2) In the case of a high-deductible health plan, benefits for male sterilization or male contraceptives shall be provided at the lowest deductible and other cost-sharing permitted for a high-deductible health plan under section 223(c)(2)(A) of the Internal Revenue Code (26 U.S.C. s.223).
d. Nothing in this section shall limit coverage of any additional preventive service for women, as identified or recommended by the United States Preventive Services Task Force or the Health Resources and Services Administration of the United States Department of Health and Human Services pursuant to the provisions of 42 U.S.C. 300gg-13.
(cf: P.L.2015, c.376, s.10)
13. (New section) The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of section 1 of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.
14. This act shall take effect immediately.
STATEMENT
This bill makes several changes regarding the coverage of contraceptive drugs available for over-the-counter sale that are approved by the United States Food and Drug Administration (FDA).
First, this bill requires Medicaid to provide coverage, without a prescription, for all female contraceptive drugs available for over-the-counter sale that are approved by the FDA. Currently, the law requires such coverage to be provided by the State Health Benefits Program, the School Employees' Health Benefits Program, and other health benefits plans.
Second, the bill places certain requirements on the coverage of contraceptive drugs available for over-the-counter sale that are approved by the FDA under Medicaid, the State Health Benefits Program, the School Employees' Health Benefits Program, and other health benefits plans. Specifically, coverage of such drugs under the bill is prohibited from requiring cost-sharing and must include the furnishing of a contraceptive drug intended to last for a 12-month period. The bill further stipulates that if the United States Food and Drug Administration has approved one or more therapeutic equivalents of a contraceptive drug for over-the-counter sale, coverage of all those therapeutically equivalent versions is not required, as long as at least one drug is covered without any cost-sharing requirement. The bill requires the covering entity to establish mechanisms to ensure that the individual eligible for coverage of a contraceptive drug has the option either to access the contraceptives at a pharmacy without a payment required at the point of sale or to make a purchase of a contraceptive drug with a payment at the point of sale and submit a claim for reimbursement to the covering entity.
The bill also revises a law authorizing pharmacists to furnish self-administered hormonal contraceptives without an individual prescription to provide that the requirements of that law, including a requirement to screen patients using a questionnaire prior to dispensing the contraceptive, do not apply to over-the-counter female contraceptive drugs approved by the FDA.
Finally, the bill expands the scope of an existing public awareness campaign informing the public about the availability of self-administered hormonal contraceptives from pharmacies without an individual prescription, to additionally include information about the availability of health benefits coverage for FDA-approved over-the-counter female contraceptive drugs under Medicaid, the State Health Benefits Program, the School Employees' Health Benefits Program, and other health benefits plans. The bill further revises the public awareness campaign to require the Commissioner of Health develop the campaign in consultation with the Commissioner of Human Services.
