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A4209
ASSEMBLY, No. 4209
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED FEBRUARY 19, 2026
Sponsored by:
Assemblywoman� CAROL A. MURPHY
District 7 (Burlington)
SYNOPSIS
���� Requires health insurers, SHBP and SEHBP to provide
coverage for diagnosis, evaluation and treatment of lymphedema.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act
requiring health insurance coverage for lymphedema
and supplementing various parts of the statutory law.
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� a.� A hospital service
corporation contract that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1938,
c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance on or after the effective date of
this act, shall provide coverage for expenses incurred in the diagnosis,
evaluation, and treatment of lymphedema that is determined to be medically
necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract.�
���� c.���� This section shall
apply to those hospital service corporation contracts in which the hospital
service corporation has reserved the right to change the premium.
���� 2.��� a.� A medical service
corporation contract that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74
(C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the
Commissioner of Banking and Insurance on or after the effective date of this
act, shall provide coverage for expenses incurred in the diagnosis, evaluation,
and treatment of lymphedema that is determined to be medically necessary by the
covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract.� �������
���� c.���� This section shall
apply to those medical service corporation contracts in which the medical
service corporation has reserved the right to change the premium.
���� 3.��� a.� A health service
corporation contract that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1985,
c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance on or after the effective date of
this act, shall provide coverage for expenses incurred in the diagnosis,
evaluation, and treatment of lymphedema that is determined to be medically
necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract.�
���� c.���� This section shall
apply to those health service corporation contracts in which the health service
corporation has reserved the right to change the premium.
���� 4.��� a.� An individual health
insurance policy that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1
et seq., or approved for issuance or renewal in this State by the Commissioner
of Banking and Insurance on or after the effective date of this act, shall
provide coverage for expenses incurred in the diagnosis, evaluation, and
treatment of lymphedema that is determined to be medically necessary by the
insured�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the policy.�
���� c.���� This section shall
apply to those individual health insurance policies in which the insurer has
reserved the right to change the premium.
���� 5.��� a.� A group health
insurance policy that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to
N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by
the Commissioner of Banking and Insurance on or after the effective date of
this act, shall provide coverage for expenses incurred in the diagnosis,
evaluation, and treatment of lymphedema that is determined to be medically
necessary by the insured�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the policy.�
���� c.���� This section shall
apply to those group health insurance policies in which the insurer has
reserved the right to change the premium.
���� 6.��� a.� An individual health
benefits plan that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1992,
c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State
by the Commissioner of Banking and Insurance on or after the effective date of
this act, shall provide coverage for expenses incurred in the diagnosis,
evaluation, and treatment of lymphedema that is determined to be medically
necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the health benefits plan.�
���� c.���� This section shall
apply to those health benefits plans in which the carrier has reserved the
right to change the premium.
���� 7.��� a.� A small employer
health benefits plan that provides hospital and medical expense benefits and is
delivered, issued, executed or renewed in this State pursuant to P.L.1992,
c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State
by the Commissioner of Banking and Insurance on or after the effective date of
this act, shall provide coverage for expenses incurred in the diagnosis,
evaluation, and treatment of lymphedema that is determined to be medically
necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the health benefits plan.�
���� c.���� This section shall
apply to those health benefits plans in which the carrier has reserved the
right to change the premium.
���� 8.��� a.� A health maintenance
organization contract for health care services that is delivered, issued,
executed, or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et
seq.), or approved for issuance or renewal in this State by the Commissioner of
Banking and Insurance, on or after the effective date of this act, shall
provide coverage for expenses incurred in the diagnosis, evaluation, and
treatment of lymphedema that is determined to be medically necessary by the
enrollee�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract for services.�
���� c.���� This section shall
apply to those contracts for health care services under which the health
maintenance organization has reserved the right to change the schedule of
charges for enrollee coverage.
���� 9.��� a.� The State Health
Benefits Commission shall ensure that every contract purchased by the
commission on or after the effective date of this act that provides hospital
and medical expense benefits shall provide coverage for expenses incurred in
the diagnosis, evaluation, and treatment of lymphedema that is determined to be
medically necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract.
���� 10.� a.� The School Employees�
Health Benefits Commission shall ensure that every contract purchased by the
commission on or after the effective date of this act that provides hospital
and medical expense benefits shall provide coverage for expenses incurred in
the diagnosis, evaluation, and treatment of lymphedema that is determined to be
medically necessary by the covered person�s physician.�
���� b.��� The benefits provided by
this section shall be provided to the same extent and with the same
deductibles, coinsurance, and other cost sharing as apply to similar services
under the contract.�
���� 11.� This act shall take
effect on the first day of the seventh month next following enactment.
STATEMENT
���� This bill requires health
insurers and health maintenance organizations, as well as health benefits plans
or contracts which are issued or purchased pursuant to the New Jersey
Individual Health Coverage Program, New Jersey Small Employer Health Benefits Program,
State Health Benefits Program, and School Employees� Health Benefits Program,
to provide coverage for expenses incurred in the diagnosis, evaluation, and
treatment of lymphedema that is determined to be medically necessary by the
treating physician.
���� Lymphedema is caused by an
abnormality of the lymphatic system leading to excessive build-up of tissue
fluid that forms lymph, known as interstitial fluid. Interstitial fluid can
build up in any area of the body that has inadequate lymph drainage and cause
lymphedema.� Left untreated, lymphedema leads to chronic inflammation,
infection and hardening of the skin that, in turn results in further lymph
vessel damage and distortion of the shape of affected body parts.� Lymphedema
is a condition that develops slowly and once present is usually progressive.�
���� Although
some people are born with abnormalities in the lymphatic system, a condition
known as Primary Lymphedema, most lymphedema in the United States is Secondary
Lymphedema.� This type of lymphedema occurs from damage to the lymphatic
system, commonly from cancer and its treatment, but also from trauma to the
skin such as from burns or infections.� Lymphedema can occur as a result of
breast cancer, melanoma, gynecologic cancer, head and neck cancer, and sarcoma.
���� Early
diagnosis of lymphedema is important since treatment is most effective when
commenced at the earliest stage of the disease.� Lymphedema has no cure, but
can be successfully managed when properly diagnosed and treated.� Every patient
diagnosed with lymphedema should have access to established effective treatment.