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A1762
ASSEMBLY, No. 1762
STATE OF NEW JERSEY
222nd LEGISLATURE
�
PRE-FILED FOR INTRODUCTION IN THE 2026 SESSION
Sponsored by:
Assemblyman ANTHONY S. VERRELLI
District 15 (Hunterdon and Mercer)
Assemblywoman VERLINA REYNOLDS-JACKSON
District 15 (Hunterdon and Mercer)
Assemblyman WILLIAM B. SAMPSON, IV
District 31 (Hudson)
Co-Sponsored by:
Assemblywoman Haider
SYNOPSIS
���� Requires health insurance carriers to provide
coverage for persons 18 or younger with diagnosed complex medical needs.
CURRENT VERSION OF TEXT
���� Introduced Pending Technical Review by Legislative
Counsel.
��
An Act
concerning insurance coverage of complex medical
needs under certain circumstances and supplementing P.L.1997, c.192 (C.26:2S-1
et seq.).
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� a.� A carrier shall
provide benefits for expenses incurred in conducting medical services,
procedures, testing, or nursing care and the purchase of medical equipment or
prescription drugs to persons 18 years of age or younger with diagnosed complex
medical needs, provided the attending licensed health care provider determines
it medically necessary.
���� b.��� Notwithstanding the
provisions of any other law, rule, or regulation to the contrary, a carrier
shall approve any benefit for a person 18 years of age or younger with
diagnosed complex medical needs within three days of receipt of a letter from
the attending licensed health care provider and shall not condition the payment
of any benefit for a medical service, procedure, or test, nursing care, or
purchase of medical equipment or prescription drug upon any pre-approval or
precertification of any kind by the carrier if that medical service, procedure,
or test, nursing care, or purchase of medical equipment or prescription drug is
otherwise covered under the health benefits plan and it has been prescribed by
a licensed health care provider.
���� c.���� As used in this
section:
���� "Carrier" means an
insurance company, health service corporation, hospital service corporation,
medical service corporation, or health maintenance organization authorized to
issue health benefits plans in this State or any entity contracted to administer
health benefits in connection with the State Health Benefits Program or School
Employees' Health Benefits Program.
���� �Complex medical needs� means:
���� (1)�� a diagnosis, treatment,
or procedure that has a high degree of outcome variation and requires
specialized skills to provide care for the individual in order to prevent a
serious adverse outcome; or
���� (2)�� a condition that is
emergent, persistent, substantially disabling, or life-threatening; requires
the use of anesthesia, other than local anesthesia; or that requires
interventions across a variety of domains of care to prevent a serious adverse
outcome.
���� 2.��� This act shall take
effect immediately and apply to health benefits plans or prescription drug
benefits plans issued or purchased on or after that date.
STATEMENT
���� This bill requires health
insurance carriers, including insurance companies, health service corporations,
hospital service corporations, medical service corporations, or health
maintenance organizations authorized to issue health benefits plans in New
Jersey or any entity contracted to administer health benefits in connection
with the State Health Benefits Program or School Employees' Health Benefits
Program to provide coverage for persons 18 years of age or younger with
diagnosed complex medical needs.� The bill requires that the benefits be
provided for expenses incurred in conducting medical services, procedures, or
testing, nursing care, and the purchase of medical equipment or prescription
drugs to persons 18 years of age or younger with diagnosed complex medical
needs, provided the attending licensed health care provider determines it
medically necessary.
���� In addition, the bill requires
that health insurance carriers and contracts for health benefits or
prescription drug benefits purchased by the State Health Benefits Program and
the School Employees� Health Benefits Program approve any benefit for a person
18 years of age or younger with diagnosed complex medical needs within three
days of receipt of a letter from the attending licensed health care provider
and shall not condition the payment of any benefit for a medical service,
procedure, test, nursing care, or purchase of medical equipment or prescription
drug upon any pre-approval or precertification of any kind if that medical
service, procedure, test, nursing care, or purchase of medical equipment or
prescription drug is otherwise covered under the health benefits plan and it
has been prescribed by a licensed health care provider.