Bill Text: NJ A4027 | 2024-2025 | Regular Session | Amended
Bill Title: Requires health insurance coverage of preimplantation genetic testing with in vitro fertilization under certain conditions.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Introduced) 2024-10-24 - Reported out of Asm. Comm. with Amendments, and Referred to Assembly Appropriations Committee [A4027 Detail]
Download: New_Jersey-2024-A4027-Amended.html
Sponsored by:
Assemblywoman SHAVONDA E. SUMTER
District 35 (Bergen and Passaic)
SYNOPSIS
Requires health insurance coverage of preimplantation genetic testing with in vitro fertilization under certain conditions.
CURRENT VERSION OF TEXT
As reported by the Assembly Financial Institutions and Insurance Committee on October 24, 2024, with amendments.
An Act concerning health insurance coverage of preimplantation genetic testing and in vitro fertilization and amending various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1[1. Section 1 of P.L.2001, c.236 (C.17:48-6x) is amended to read as follows:
1. a. A hospital service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The hospital service corporation contract shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The hospital service corporation may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The hospital service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or that the patient has met one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
[b] d. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer and intracytoplasmic sperm injection, if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches or any group or entity that is operated, supervised or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] e. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
[d] f. The provisions of this section shall not apply to a hospital service corporation contract which, pursuant to a contract between the hospital service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
(cf: P.L.2017, c.48, s.1)]1
1[2. Section 2 of P.L.2001, c.236 (C.17:48A-7w) is amended to read as follows:
2. a. A medical service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The medical service corporation contract shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The medical service corporation may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The medical service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or that the patient has met one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
[b] d. A religious employer may request, and a medical service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer and intracytoplasmic sperm injection, if the required coverage is contrary to the religious employer's bona fide religious tenets. The medical service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than ten point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches or any group or entity that is operated, supervised or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] e. This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
[d] f. The provisions of this section shall not apply to a medical service corporation contract which, pursuant to a contract between the medical service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
(cf: P.L.2017, c.48, s.2)]1
1[3. Section 3 of P.L.2001, c.236 (C.17:48E-35.22) is amended to read as follows:
3. a. A health service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The health service corporation contract shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The health service corporation may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The health service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or that the patient has met one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
[b] d. A religious employer may request, and a health service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer and intracytoplasmic sperm injection, if the required coverage is contrary to the religious employer's bona fide religious tenets. The health service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than ten point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches or any group or entity that is operated, supervised or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] e. This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.
[d] f. The provisions of this section shall not apply to a health service corporation contract which, pursuant to a contract between the health service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
(cf: P.L.2017, c.48, s.3)]1
1[4. Section 4 of P.L.2001, c.236 (C.17B:27-46.1x) is amended to read as follows:
4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the policy provides coverage for persons covered under the policy for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The policy shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The insurer may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The insurer may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or that the patient has met one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the policy, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the policy. Infertility resulting from voluntary sterilization procedures shall be excluded under the policy for the coverage required by this section.
[b] d. A religious
employer may request, and an insurer shall grant, an exclusion under the policy
for the coverage required by this section for in vitro fertilization, embryo
transfer, artificial insemination, zygote intra fallopian transfer and
intracytoplasmic sperm injection, if the required coverage is contrary to the
religious employer's bona fide religious tenets. The insurer that issues a
policy containing such an exclusion shall provide written notice thereof to
each prospective insured or insured, which shall appear in not less than ten
point type, in the policy, application and sales brochure. For the purposes of
this subsection, "religious employer" means an employer that is a
church, convention or association of churches or any group or entity that is
operated, supervised or controlled by or in connection with a church or a
convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A),
and that qualifies as a tax-exempt organization under
26 U.S.C. s.501(c)(3).
[c] e. This section shall apply to those insurance policies in which the insurer has reserved the right to change the premium.
[d] f. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
(cf: P.L.2017, c.48, s.4)]1
1[5. Section 5 of P.L.2001, c.236 (C.26:2J-4.23) is amended to read as follows:
5. a. No certificate of authority to establish and operate a health maintenance organization in this State shall be issued or continued on or after the effective date of this act unless the health maintenance organization provides health care services, to groups of more than 50 enrollees, for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. A health maintenance organization shall provide enrollee coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the enrollee. The health maintenance organization may provide that health care services for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The health maintenance organization may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or that the patient has met one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The health care services shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical health care services under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
[b] d. A religious employer may request, and a health maintenance organization shall grant, an exclusion under the contract for the health care services required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer and intracytoplasmic sperm injection, if the required health care services are contrary to the religious employer's bona fide religious tenets. The health maintenance organization that issues a contract containing such an exclusion shall provide written notice thereof to each prospective enrollee or enrollee, which shall appear in not less than ten point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches or any group or entity that is operated, supervised or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] e. 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.
[d] f. The provisions of this section shall not apply to a contract for health care services by a health maintenance organization which, pursuant to a contract between the health maintenance organization and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
(cf: P.L.2017, c.48, s.5)]1
1[6. Section 6 of P.L.2017, c.48 (C.52:14-17.29v) is amended to read as follows:
6. a. The State Health Benefits Commission shall ensure that every contract under the State Health Benefits Program shall provide coverage for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The State Health Benefits Program contract shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The State Health Benefits Commission may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The State Health Benefits Commission may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or any one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
(cf: P.L.2017, c.48, s.6)]1
1[7. Section 7 of P.L.2017, c.48 (C.52:14-17.46.6g) is amended to read as follows:
7. a. The School Employees Health Benefits Commission shall ensure that every contract under the School Employees Health Benefits Program shall provide coverage for medically necessary expenses incurred in the diagnosis and treatment of infertility, as provided pursuant to this section, and for preimplantation genetic testing, including in vitro fertilization, where the covered persons are not infertile, for the purpose of preventing certain serious genetic conditions from being passed on to offspring. The School Employees Health Benefits Program contract shall provide coverage which includes, but is not limited to, the following services related to infertility: diagnosis and diagnostic tests; medications; surgery; in vitro fertilization; embryo transfer; artificial insemination; gamete intra fallopian transfer; zygote intra fallopian transfer; intracytoplasmic sperm injection; and four completed egg retrievals per lifetime of the covered person. The School Employees Health Benefits Commission may provide that coverage for in vitro fertilization, gamete intra fallopian transfer and zygote intra fallopian transfer shall be limited to a covered person who: a. has used all reasonable, less expensive and medically appropriate treatments and is still unable to become pregnant or carry a pregnancy; b. has not reached the limit of four completed egg retrievals; and c. is 45 years of age or younger. The School Employees Health Benefits Commission may also provide that coverage for preimplantation genetic testing with in vitro fertilization be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
b. [For purposes of] As used in this section[,]:
["infertility"] "Infertility" means a disease or condition that results in the abnormal function of the reproductive system, as determined pursuant to American Society for Reproductive Medicine practice guidelines by a physician who is Board Certified or Board Eligible in Reproductive Endocrinology and Infertility or in Obstetrics and Gynecology or any one of the following conditions:
(1) A male is unable to impregnate a female;
(2) A female with a male partner and under 35 years of age is unable to conceive after 12 months of unprotected sexual intercourse;
(3) A female with a male partner and 35 years of age and over is unable to conceive after six months of unprotected sexual intercourse;
(4) A female without a male partner and under 35 years of age who is unable to conceive after 12 failed attempts of intrauterine insemination under medical supervision;
(5) A female without a male partner and over 35 years of age who is unable to conceive after six failed attempts of intrauterine insemination under medical supervision;
(6) Partners are unable to conceive as a result of involuntary medical sterility;
(7) A person is unable to carry a pregnancy to live birth; or
(8) A previous determination of infertility pursuant to this section.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
c. The benefits shall be provided to the same extent as for other pregnancy-related procedures under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from voluntary sterilization procedures shall be excluded under the contract for the coverage required by this section.
(cf: P.L.2017, c.48, s.7)]1
11. Section 1 of P.L.2001, c.236 (C.17:48-6x) is amended to read as follows:
1. a. A hospital service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The hospital service corporation contract shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The hospital service corporation may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The hospital service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.
[b] e. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] f. This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
[d] g. The provisions of this section shall not apply to a hospital service corporation contract which, pursuant to a contract between the hospital service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
[e] h. Nothing in this section shall preclude the hospital service corporation from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.1)
12. Section 2 of P.L.2001, c.236 (C.17:48A-7w) is amended to read as follows:
2. a. A medical service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The medical service corporation contract shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The medical service corporation may provide that coverage for in vitro fertilization , with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The medical service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.
[b] e. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] f. This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
[d]g. The provisions of this section shall not apply to a medical service corporation contract which, pursuant to a contract between the medical service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
[e] h. Nothing in this section shall preclude the medical service corporation from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.2)
13. Section 3 of P.L.2001, c.236 (C.17:48E-35.22) is amended to read as follows:
3. a. A health service corporation contract which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the contract provides coverage for persons covered under the contract for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The health service corporation contract shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The health service corporation may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The health service corporation may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.
[b] e. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] f. This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.
[d] g. The provisions of this section shall not apply to a health service corporation contract which, pursuant to a contract between the health service corporation and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
[e] h. Nothing in this section shall preclude the health service corporation from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.3)
14. Section 4 of P.L.2001, c.236 (C.17B:27-46.1x) is amended to read as follows:
4. a. A group health insurance policy which provides hospital or medical expense benefits for groups with more than 50 persons, which includes pregnancy-related benefits, shall not be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act unless the policy provides coverage for persons covered under the policy for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The policy shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The policy may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A policy shall not impose any restriction concerning the coverage of infertility services based on age.
b. The policy may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the policy, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.
[b] e. A religious employer may request, and a hospital service corporation shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] f. This section shall apply to those insurance policies in which the insurer has reserved the right to change the premium.
[d] g. The provisions of this section shall not apply to a group health insurance policy which, pursuant to a contract between the insurer and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
[e] h. Nothing in this section shall preclude the insurer from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.4)
15. Section 5 of P.L.2001, c.236 (C.26:2J-4.23) is amended to read as follows:
5. a. No certificate of authority to establish and operate a health maintenance organization in this State shall be issued or continued on or after the effective date of this act unless the health maintenance organization provides health care services, to groups of more than 50 enrollees, for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. A health maintenance organization shall provide enrollee coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. A health maintenance organization may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The health maintenance organization may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed.
[b] e. A religious employer may request, and a health maintenance organization shall grant, an exclusion under the contract for the coverage required by this section for in vitro fertilization, embryo transfer, artificial insemination, zygote intra fallopian transfer, and intracytoplasmic sperm injection if the required coverage is contrary to the religious employer's bona fide religious tenets. The hospital service corporation that issues a contract containing such an exclusion shall provide written notice thereof to each prospective subscriber or subscriber, which shall appear in not less than 10 point type, in the contract, application and sales brochure. For the purposes of this subsection, "religious employer" means an employer that is a church, convention or association of churches, or any group or entity that is operated, supervised, or controlled by or in connection with a church or a convention or association of churches as defined in 26 U.S.C. s.3121(w)(3)(A), and that qualifies as a tax-exempt organization under 26 U.S.C. s.501(c)(3).
[c] f. 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.
[d] g. The provisions of this section shall not apply to a contract for health care services by a health maintenance organization which, pursuant to a contract between the health maintenance organization and the Department of Human Services, provides benefits to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.), the NJ FamilyCare Program established pursuant to P.L.2005, c.156 (C.30:4J-8 et al.), or any other program administered by the Division of Medical Assistance and Health Services in the Department of Human Services.
[e] h. Nothing in this section shall preclude the health maintenance organization from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.5)
16. Section 6 of P.L.2017, c.48 (C.52:14-17.29v) is amended to read as follows:
6. a. The State Health Benefits Commission shall ensure that every contract under the State Health Benefits Program shall provide coverage for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The State Health Benefits Program shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The State Health Benefits Commission may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The State Health Benefits Commission may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.6)
17. Section 7 of P.L.2017, c.48 (C.52:14-17.46.6g) is amended to read as follows:
7. a. The School Employees Health Benefits Commission shall ensure that every contract under the School Employees Health Benefits Program shall provide coverage for medically necessary expenses, as determined by a physician, incurred in the diagnosis and treatment of infertility as provided pursuant to this section. The School Employees Health Benefits Program contract shall provide coverage for any services related to infertility in accordance with American Society for Reproductive Medicine guidelines and as determined by a physician, which includes, but is not limited to: diagnosis and diagnostic tests; medications; surgery; intrauterine insemination; in vitro fertilization, including in vitro fertilization using donor eggs and in vitro fertilization where the embryo is transferred to a gestational carrier or surrogate; genetic testing; preimplantation genetic testing, including in vitro fertilization, where the covered person is not infertile for the purpose of preventing certain serious genetic conditions from being passed to offspring; artificial insemination; intracytoplasmic sperm injection; four completed egg retrievals; unlimited embryo transfers, in accordance with guidelines from the American Society for Reproductive Medicine, using single embryo transfer when recommended and deemed medically appropriate by a physician; and medical costs of egg or sperm donors, including office visits, medications, laboratory and radiological procedures, and retrieval, shall be covered until the donor is released from treatment by the reproductive endocrinologist. The School Employees Health Benefits Commission may provide that coverage for in vitro fertilization, with exception to preimplantation genetic testing with in vitro fertilization, shall be limited to a covered person who has used all reasonable, less expensive, and medically appropriate treatments, as determined by a licensed physician, and is still unable to become pregnant or carry a pregnancy to a live birth. Coverage for infertility services provided to partners of persons who have successfully reversed a voluntary sterilization shall not be excluded. A contract shall not impose any restriction concerning the coverage of infertility services based on age.
b. The State Health Benefits Commission may also provide that coverage for preimplantation genetic testing with in vitro fertilization, as provided pursuant to subsection a. of this section, be limited to covered persons where:
(1) both partners are known carriers of an autosomal recessive disorder;
(2) one partner is a known carrier of a single gene autosomal recessive disorder and the partners have one offspring that has been diagnosed with that recessive disorder;
(3) one partner is a known carrier of a single gene autosomal disorder;
(4) one partner is a known carrier of a single X-linked disorder; and
(5) the genetic condition, if passed on to the covered persons' offspring, would result in significant health problems or severe disability.
c. As used in this section:
"Infertility" means a disease, condition, or status characterized by any of the following:
(1) the inability to achieve a successful pregnancy based on a patient's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors;
(2) the need for medical intervention, including, but not limited to, the use of donor gametes or donor embryos in order to achieve a successful pregnancy either as an individual or with a partner; or
(3) in patients having regular, unprotected intercourse and without any known etiology for either partner suggestive of impaired reproductive ability, evaluation should be initiated at 12 months when the female partner is under 35 years of age and at 6 months when the female partner is 35 years of age or older.
Nothing in this definition shall be used to deny or delay treatment to any individual, regardless of relationship status or sexual orientation.
"Preimplantation genetic testing" means a technique used to identify genetic defects in embryos created through in vitro fertilization before pregnancy.
"Treatment of infertility" means the recommended treatment plan or prescribed procedures, services, and medications as directed by a licensed physician for infertility as defined in this section.
d. The benefits shall be provided to the same extent as for other medical conditions under the contract, except that the services provided for in this section shall be performed at facilities that conform to standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists. The same copayments, deductibles and benefit limits shall apply to the diagnosis and treatment of infertility pursuant to this section as those applied to other medical or surgical benefits under the contract. Infertility resulting from a voluntary unreversed sterilization procedure may be excluded under the contract if the voluntary unreversed sterilization is the sole cause of infertility, provided, however, that coverage for infertility services shall not be excluded if the voluntary sterilization is successfully reversed. Nothing in this section shall preclude the carrier from performing utilization review, including periodic review of the medical necessity of a particular service, provided all utilization review decisions are consistent with American Society for Reproductive Medicine guidelines.1
(cf: P.L.2023, c.258, s.7)
8. This act shall take effect on the 90th day next following enactment and shall apply to policies or contracts delivered, issued, or renewed on or after that date.
